Healthcare Provider Details

I. General information

NPI: 1346780582
Provider Name (Legal Business Name): VIRGINIA M MITCHELL DDS P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MARKET ST
CENTEREACH NY
11720-2246
US

IV. Provider business mailing address

14 MARKET ST
CENTEREACH NY
11720-2246
US

V. Phone/Fax

Practice location:
  • Phone: 631-588-8890
  • Fax:
Mailing address:
  • Phone: 631-588-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number040954
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. VIRGINIA M. MITCHELL
Title or Position: DENTIST/OWNER
Credential: D.D.S.
Phone: 631-588-8890