Provider Demographics
NPI:1811329279
Name:MIMS, IRA EUGENE II (DDS)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:EUGENE
Last Name:MIMS
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 W MAIN ST
Mailing Address - Street 2:STE 205
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3394
Mailing Address - Country:US
Mailing Address - Phone:972-436-0788
Mailing Address - Fax:972-436-9188
Practice Address - Street 1:1565 W MAIN ST
Practice Address - Street 2:#205
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3394
Practice Address - Country:US
Practice Address - Phone:972-436-0788
Practice Address - Fax:972-436-9188
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29332122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323777803Medicaid