MEDICARE: STEPHEN JOHN MIXON DMD

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	1223G0001X	General Practice Dentistry	DNO12775	GA

General Provider Information

NPI Number	:	1942396155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN JOHN MIXON DMD

Provider Business Mailing Address
First Line	:	6501 PEAKE RD
Second Line	:	BLDG 600
City	:	MACON
State	:	GA
Zip	:	31210-8042
Country	:	US
Telephone Number	:	478-477-7101
Fax Number	:	478-477-1728

Provider Business Practice Location Address
First Line	:	6501 PEAKE RD
Second Line	:	BLDG 600
City	:	MACON
State	:	GA
Zip	:	31210-8042
Country	:	US
Telephone Number	:	478-477-7101
Fax Number	:	478-477-1728

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/08/2007

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