Provider Demographics
NPI:1730101031
Name:MITCHELL, MELVIN G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:G
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MELVIN
Other - Middle Name:G
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:704 S BROADWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1674
Mailing Address - Country:US
Mailing Address - Phone:615-325-9837
Mailing Address - Fax:
Practice Address - Street 1:704 S BROADWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1674
Practice Address - Country:US
Practice Address - Phone:615-325-9837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS29341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3202641Medicaid
TN0192607OtherBC/BS