Provider Demographics
NPI:1235238221
Name:MITCHAM, IVY BASS (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:BASS
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 W GRAND PARKWAY S #1200
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494
Mailing Address - Country:US
Mailing Address - Phone:281-395-1700
Mailing Address - Fax:281-395-1725
Practice Address - Street 1:1575 W GRAND PARKWAY S #1200
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494
Practice Address - Country:US
Practice Address - Phone:281-395-1700
Practice Address - Fax:281-395-1725
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15439122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist