Provider Demographics
NPI:1114908084
Name:MITNITSKY, EDWARD FRANCIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:FRANCIS
Last Name:MITNITSKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 DYNASTY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-6617
Mailing Address - Country:US
Mailing Address - Phone:707-864-1027
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:60TH DENTAL SQUADRON/SGDT
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-7072
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025869L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice