Provider Demographics
NPI:1578712980
Name:MITCHELL DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:MITCHELL DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-285-6828
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-0068
Mailing Address - Country:US
Mailing Address - Phone:662-285-6828
Mailing Address - Fax:662-285-6896
Practice Address - Street 1:103 N LOUISVILLE ST
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735-9147
Practice Address - Country:US
Practice Address - Phone:662-285-6828
Practice Address - Fax:662-285-6896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03806868Medicaid