Provider Demographics
NPI:1275649394
Name:PAGE, MITCHELL LEE (DDS, MS)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:LEE
Last Name:PAGE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15875 95TH AVENUE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369
Mailing Address - Country:US
Mailing Address - Phone:763-233-4140
Mailing Address - Fax:763-420-3158
Practice Address - Street 1:15785 95TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4404
Practice Address - Country:US
Practice Address - Phone:763-233-4140
Practice Address - Fax:763-420-3158
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31791223E0200X
MN102111223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN391719255OtherDELTA DENTAL
MN48114PAOtherBC/BS