Healthcare Provider Details

I. General information

NPI: 1518045772
Provider Name (Legal Business Name): SAMUEL EDWARD MITCHELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MISSION ROAD
FORT HALL ID
83203
US

IV. Provider business mailing address

1222 FREEMAN LANE APT 67
POCATELLO ID
83201
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-5446
  • Fax: 208-238-5463
Mailing address:
  • Phone: 208-478-6650
  • Fax: 208-238-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number052435
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: