Provider Demographics
NPI:1790798601
Name:MITCHELL, JOHN HERMAN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HERMAN
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:352 MISSION DRIVE
Mailing Address - City:SIMMESPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71369
Mailing Address - Country:US
Mailing Address - Phone:318-941-2071
Mailing Address - Fax:318-941-2629
Practice Address - Street 1:352 MISSION DRIVE
Practice Address - Street 2:
Practice Address - City:SIMMESPORT
Practice Address - State:LA
Practice Address - Zip Code:71369
Practice Address - Country:US
Practice Address - Phone:318-941-2071
Practice Address - Fax:318-941-2629
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA34401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1834408Medicaid