MEDICARE: DR. GRIFFIN E. MIZELL D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	9762	GA

General Provider Information

NPI Number	:	1316118383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. GRIFFIN E. MIZELL D.D.S

Provider Business Mailing Address
First Line	:	100 W PARSONAGE ST
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-1735
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 W PARSONAGE ST
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-1735
Country	:	US
Telephone Number	:	229-868-6615
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. GRIFFIN E. MIZELL JR.
Credential	:
Telephone Number	:	229-868-6615

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	03/18/2008

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