MEDICARE: DR. BONNY G MITCHELL 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	11985	MD
2	122300000X	Dentist	7595	MD
3	122300000X	Dentist	7646	MD

General Provider Information

NPI Number	:	1891719654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONNY G MITCHELL D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 364
Second Line	:
City	:	DAVIDSONVILLE
State	:	MD
Zip	:	21035-0364
Country	:	US
Telephone Number	:	410-956-5555
Fax Number	:	410-798-5165

Provider Business Practice Location Address
First Line	:	3102 DAVIDSONVILLE RD
Second Line	:
City	:	DAVIDSONVILLE
State	:	MD
Zip	:	21035-1803
Country	:	US
Telephone Number	:	410-956-5555
Fax Number	:	410-798-5165

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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