Provider Demographics
NPI:1699042655
Name:MITCHELL, SUSANNAH MARTHA (DMD)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:MARTHA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 CRYSTAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:MANITOU SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80829-2841
Mailing Address - Country:US
Mailing Address - Phone:617-935-4564
Mailing Address - Fax:
Practice Address - Street 1:6110 BARNES RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2600
Practice Address - Country:US
Practice Address - Phone:719-630-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9121122300000X
TX24179122300000X
CO10704122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist