Provider Demographics
NPI:1154475226
Name:MITSCHKE, SAMUEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:MITSCHKE
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 1:201 OAK DR S
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5676
Mailing Address - Country:US
Mailing Address - Phone:979-297-2491
Mailing Address - Fax:979-297-3468
Practice Address - Street 1:201 OAK DR S
Practice Address - Street 2:SUITE 206
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5676
Practice Address - Country:US
Practice Address - Phone:979-297-2491
Practice Address - Fax:979-297-3468
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice