Provider Demographics
NPI:1932289204
Name:MITCHELL, JERRY WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WAYNE
Last Name:MITCHELL
Suffix:
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 4378
Mailing Address - Street 2:620 FIRST AVE N
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-0000
Mailing Address - Country:US
Mailing Address - Phone:208-720-7368
Mailing Address - Fax:
Practice Address - Street 1:620 FIRST AVE N
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-0000
Practice Address - Country:US
Practice Address - Phone:208-720-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000052951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice