Healthcare Provider Details

I. General information

NPI: 1952467425
Provider Name (Legal Business Name): DR. SHELLY MIXSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3528 ASHFORD DUNWOODY ROAD
ATLANTA GA
30319
US

IV. Provider business mailing address

1133 E WEST CONNECTOR STE. 120 & 130
AUSTELL GA
30106-1589
US

V. Phone/Fax

Practice location:
  • Phone: 770-455-6602
  • Fax:
Mailing address:
  • Phone: 770-333-9951
  • Fax: 770-333-9953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number012436
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: