Provider Demographics
NPI:1689643777
Name:MIXER, JOHN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:MIXER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1150 E SHERMAN BLVD
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1871
Mailing Address - Country:US
Mailing Address - Phone:231-733-1571
Mailing Address - Fax:231-733-5228
Practice Address - Street 1:1150 E SHERMAN BLVD
Practice Address - Street 2:SUITE 1600
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1871
Practice Address - Country:US
Practice Address - Phone:231-733-1571
Practice Address - Fax:231-733-5228
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010114111223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4193792Medicaid
MI4204519Medicaid
MI97 0 F1 1036 0OtherBLUE CROSS MEDICAL
MID800376OtherBLUE CROSS DENTAL
MI4204519Medicaid
MI97 0 F1 1036 0OtherBLUE CROSS MEDICAL