Healthcare Provider Details

I. General information

NPI: 1699085498
Provider Name (Legal Business Name): MITCHELL INDICTOR, D.D.S., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 SE 23RD AVE SUITE 100
BOYNTON BEACH FL
33435-7653
US

IV. Provider business mailing address

207 SE 23RD AVE SUITE 100
BOYNTON BEACH FL
33435-7653
US

V. Phone/Fax

Practice location:
  • Phone: 561-734-8600
  • Fax: 561-738-6672
Mailing address:
  • Phone: 561-734-8600
  • Fax: 561-738-6672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MITCHELL INDICTOR
Title or Position: PRESIDENT/DIRECTOR
Credential: D.D.S.
Phone: 561-734-8600