Provider Demographics
NPI:1972673135
Name:ROSE-MIZE, IDA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:LYNN
Last Name:ROSE-MIZE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 THORNTON RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-1591
Mailing Address - Country:US
Mailing Address - Phone:770-745-5886
Mailing Address - Fax:770-745-5897
Practice Address - Street 1:540 THORNTON RD
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1591
Practice Address - Country:US
Practice Address - Phone:770-745-5897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126311223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry