Provider Demographics
NPI:1629342092
Name:MITCHELL, QUINN (BDS)
Entity Type:Individual
Prefix:
First Name:QUINN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E PRAIRIE ST
Mailing Address - Street 2:HERITAGE ENDODONTICS
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3818
Mailing Address - Country:US
Mailing Address - Phone:360-504-3636
Mailing Address - Fax:360-504-3536
Practice Address - Street 1:128 E PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3818
Practice Address - Country:US
Practice Address - Phone:360-504-3636
Practice Address - Fax:360-504-3536
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 194471223E0200X
WA600554261223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004716800Medicaid
FLDN19447OtherSTATE LICENSE