Healthcare Provider Details

I. General information

NPI: 1972673135
Provider Name (Legal Business Name): IDA LYNN ROSE-MIZE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 THORNTON RD
LITHIA SPRINGS GA
30122-1591
US

IV. Provider business mailing address

540 THORNTON RD
LITHIA SPRINGS GA
30122-1591
US

V. Phone/Fax

Practice location:
  • Phone: 770-745-5897
  • Fax:
Mailing address:
  • Phone: 770-745-5886
  • Fax: 770-745-5897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN012631
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: