Provider Demographics
NPI:1790190692
Name:DRISCOLL, MITCH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITCH
Middle Name:
Last Name:DRISCOLL
Suffix:
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 1:81 W WASHINGTON AVE
Mailing Address - Street 2:PO BOX 837
Mailing Address - City:ABERDEEN
Mailing Address - State:ID
Mailing Address - Zip Code:83210-4801
Mailing Address - Country:US
Mailing Address - Phone:208-397-4198
Mailing Address - Fax:208-397-5606
Practice Address - Street 1:81 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:ID
Practice Address - Zip Code:83210-4801
Practice Address - Country:US
Practice Address - Phone:208-397-4198
Practice Address - Fax:208-397-5606
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4644122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist