Provider Demographics
NPI:1093372039
Name:NEWSOME, AUSTIN MITCHELL (LD)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:MITCHELL
Last Name:NEWSOME
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 CURTIS AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1619
Mailing Address - Country:US
Mailing Address - Phone:541-604-6053
Mailing Address - Fax:
Practice Address - Street 1:215 CURTIS AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1619
Practice Address - Country:US
Practice Address - Phone:541-604-6053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN60778096122400000X
ORDT-DO-10224514122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDT-DO-10224514OtherOREGON HEALTH LICENSING BOARD OF DENTURE TECHNOLOGY
MTDEN-DTR-LIC-23568OtherSTATE OF MONTANA BUSINESS STANDARDS DIVISION
WADN60778096OtherWASHINGTON DEPARTMENT OF HEALTH