Provider Demographics
NPI:1275157299
Name:MITCHELL, JIM SR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:
Last Name:MITCHELL
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 S GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-6203
Mailing Address - Country:US
Mailing Address - Phone:405-294-9090
Mailing Address - Fax:
Practice Address - Street 1:1929 S GREEN AVE
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-6203
Practice Address - Country:US
Practice Address - Phone:405-294-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice