Provider Demographics
NPI:1043515976
Name:BRANDON T. MITCHELL, DDS, PLLC
Entity Type:Organization
Organization Name:BRANDON T. MITCHELL, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:T
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-358-2522
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WV
Mailing Address - Zip Code:26807-0145
Mailing Address - Country:US
Mailing Address - Phone:304-358-2522
Mailing Address - Fax:
Practice Address - Street 1:161 SOUTH BRANCH STREET
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WV
Practice Address - Zip Code:26807
Practice Address - Country:US
Practice Address - Phone:304-358-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3854122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015545Medicaid