Provider Demographics
NPI:1518045772
Name:MITCHELL, SAMUEL EDWARD (DDS)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:EDWARD
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 1:1222 FREEMAN LANE
Mailing Address - Street 2:APT 67
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-478-6650
Mailing Address - Fax:208-238-5463
Practice Address - Street 1:MISSION ROAD
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203
Practice Address - Country:US
Practice Address - Phone:208-238-5446
Practice Address - Fax:208-238-5463
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist