Provider Demographics
NPI:1982018842
Name:GOLDEN, MITZY A
Entity Type:Individual
Prefix:
First Name:MITZY
Middle Name:A
Last Name:GOLDEN
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 1:1000 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-9253
Mailing Address - Country:US
Mailing Address - Phone:217-345-3555
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9253
Practice Address - Country:US
Practice Address - Phone:217-345-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-030005122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist