Provider Demographics
NPI:1720764764
Name:PALMER, MITCHELL JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:JOHN
Last Name:PALMER
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 1:4016 LEMAY FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1858
Mailing Address - Country:US
Mailing Address - Phone:314-627-0209
Mailing Address - Fax:
Practice Address - Street 1:4016 LEMAY FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1858
Practice Address - Country:US
Practice Address - Phone:314-627-0209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190344081223G0001X
MO20230265031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice