Healthcare Provider Details

I. General information

NPI: 1588848360
Provider Name (Legal Business Name): GEORGE RICHARD MIXON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 PEAKE RD BLDG 600
MACON GA
31210-8042
US

IV. Provider business mailing address

6501 PEAKE RD BLDG 600
MACON GA
31210-8042
US

V. Phone/Fax

Practice location:
  • Phone: 478-477-7101
  • Fax: 478-477-1728
Mailing address:
  • Phone: 478-477-7101
  • Fax: 478-477-1728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7776
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: