Provider Demographics
NPI:1336466010
Name:MITCHELL, JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MITCHELL
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 1:305 E 55TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4148
Mailing Address - Country:US
Mailing Address - Phone:212-755-3355
Mailing Address - Fax:212-935-6964
Practice Address - Street 1:305 E 55TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4148
Practice Address - Country:US
Practice Address - Phone:212-755-3355
Practice Address - Fax:212-935-6964
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry