Provider Demographics
NPI:1942396155
Name:MIXON, STEPHEN JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:MIXON
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 1:6501 PEAKE RD
Mailing Address - Street 2:BLDG 600
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-8042
Mailing Address - Country:US
Mailing Address - Phone:478-477-7101
Mailing Address - Fax:478-477-1728
Practice Address - Street 1:6501 PEAKE RD
Practice Address - Street 2:BLDG 600
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-8042
Practice Address - Country:US
Practice Address - Phone:478-477-7101
Practice Address - Fax:478-477-1728
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO127751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice