Provider Demographics
NPI:1376982397
Name:MIZZELL, MARK JACKSON JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JACKSON
Last Name:MIZZELL
Suffix:JR
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 1:7701 WHITE HORSE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-1827
Mailing Address - Country:US
Mailing Address - Phone:864-246-1811
Mailing Address - Fax:
Practice Address - Street 1:7701 WHITE HORSE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-1827
Practice Address - Country:US
Practice Address - Phone:864-246-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC82281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice