Provider Demographics
NPI:1386634343
Name:MITCHELL, MARK WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WAYNE
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 1:6731 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-1928
Mailing Address - Country:US
Mailing Address - Phone:727-842-5180
Mailing Address - Fax:727-846-0755
Practice Address - Street 1:6731 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-1928
Practice Address - Country:US
Practice Address - Phone:727-842-5180
Practice Address - Fax:727-846-0755
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN108021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072932900Medicaid
FL67483XMedicare PIN