1518045772 NPI number — MR. SAMUEL EDWARD MITCHELL DDS

Table of content: MR. SAMUEL EDWARD MITCHELL DDS (NPI 1518045772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518045772 NPI number — MR. SAMUEL EDWARD MITCHELL DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
SAMUEL
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518045772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1222 FREEMAN LANE
Provider Second Line Business Mailing Address:
APT 67
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-478-6650
Provider Business Mailing Address Fax Number:
208-238-5463

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MISSION ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT HALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-5446
Provider Business Practice Location Address Fax Number:
208-238-5463
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  052435 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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