Provider Demographics
NPI:1639224231
Name:MITCHELL, JOHN D JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:DMD
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 306
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341
Mailing Address - Country:US
Mailing Address - Phone:662-285-6828
Mailing Address - Fax:662-285-6896
Practice Address - Street 1:59 FRONTAGE RD N
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341
Practice Address - Country:US
Practice Address - Phone:662-726-4344
Practice Address - Fax:662-285-6896
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2685-921223G0001X, 122300000X
MS2685920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03806868Medicaid