Provider Demographics
NPI:1912531781
Name:MITCHELL, HYRUM KENNETH (DMD)
Entity Type:Individual
Prefix:
First Name:HYRUM
Middle Name:KENNETH
Last Name:MITCHELL
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 1:5855 E STILL CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3631
Mailing Address - Country:US
Mailing Address - Phone:480-248-8100
Mailing Address - Fax:
Practice Address - Street 1:1067 TWINING DR
Practice Address - Street 2:
Practice Address - City:BARKSDALE AFB
Practice Address - State:LA
Practice Address - Zip Code:71110-2486
Practice Address - Country:US
Practice Address - Phone:318-456-6718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11767177-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice