Provider Demographics
NPI:1043350507
Name:MISTELE, MICHELLE LYNNE (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNNE
Last Name:MISTELE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-3015
Mailing Address - Country:US
Mailing Address - Phone:803-276-1329
Mailing Address - Fax:
Practice Address - Street 1:3533 DREHER SHOALS RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-9115
Practice Address - Country:US
Practice Address - Phone:803-732-3001
Practice Address - Fax:803-732-3190
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0033371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9727Medicaid