Provider Demographics
NPI:1952467425
Name:MIXSON, SHELLY
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:
Last Name:MIXSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 E WEST CONNECTOR
Mailing Address - Street 2:STE. 120 & 130
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1589
Mailing Address - Country:US
Mailing Address - Phone:770-333-9951
Mailing Address - Fax:770-333-9953
Practice Address - Street 1:3528 ASHFORD DUNWOODY ROAD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319
Practice Address - Country:US
Practice Address - Phone:770-455-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0124361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice