Provider Demographics
NPI:1588675102
Name:MITCHELL, ROYAL WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROYAL
Middle Name:WADE
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 1:3082 S DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6418
Mailing Address - Country:US
Mailing Address - Phone:417-887-2441
Mailing Address - Fax:417-887-7242
Practice Address - Street 1:3082 S DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6418
Practice Address - Country:US
Practice Address - Phone:417-887-2441
Practice Address - Fax:417-887-7242
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice