Provider Demographics
NPI:1467609875
Name:MITHCELL, JEROME (DDS)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:MITHCELL
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:PO BOX 6321
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-6321
Mailing Address - Country:US
Mailing Address - Phone:309-310-3273
Mailing Address - Fax:
Practice Address - Street 1:200 W FRONT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5048
Practice Address - Country:US
Practice Address - Phone:309-888-5533
Practice Address - Fax:309-888-5896
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190175361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice