Provider Demographics
NPI:1659784395
Name:MITCH CONDITT DDS PLLC
Entity Type:Organization
Organization Name:MITCH CONDITT DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:CONDITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-737-5155
Mailing Address - Street 1:6316 CAMP BOWIE BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5418
Mailing Address - Country:US
Mailing Address - Phone:817-737-5155
Mailing Address - Fax:
Practice Address - Street 1:6316 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5418
Practice Address - Country:US
Practice Address - Phone:817-737-5155
Practice Address - Fax:817-737-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14612122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty