Provider Demographics
NPI:1245385525
Name:INDICTOR, MITCHELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:INDICTOR
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 1:207 SE 23RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7653
Mailing Address - Country:US
Mailing Address - Phone:561-734-8600
Mailing Address - Fax:561-738-6652
Practice Address - Street 1:207 SE 23RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7653
Practice Address - Country:US
Practice Address - Phone:561-734-8600
Practice Address - Fax:561-738-6652
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-00096351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT94143Medicare UPIN
FL60384AMedicare ID - Type Unspecified