Provider Demographics
NPI:1184648982
Name:CONDITT, MITCHELL ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ALLEN
Last Name:CONDITT
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 1:6316 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5418
Mailing Address - Country:US
Mailing Address - Phone:817-737-5155
Mailing Address - Fax:817-737-4095
Practice Address - Street 1:5722 LOCKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5020
Practice Address - Country:US
Practice Address - Phone:817-527-8500
Practice Address - Fax:817-527-8512
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice