Healthcare Provider Details

I. General information

NPI: 1699343004
Provider Name (Legal Business Name): ELIZABETH MIZELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2021
Last Update Date: 06/12/2021
Certification Date: 06/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11412 J B HOLIDAY RD
BOGALUSA LA
70427-0998
US

IV. Provider business mailing address

11412 J B HOLIDAY RD
BOGALUSA LA
70427-0998
US

V. Phone/Fax

Practice location:
  • Phone: 985-735-9722
  • Fax:
Mailing address:
  • Phone: 985-735-9722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3JC45237159V
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: