Healthcare Provider Details

I. General information

NPI: 1215140108
Provider Name (Legal Business Name): DR. MARVA MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 MORNINGSIDE AVENUE
NEW YORK NY
10027
US

IV. Provider business mailing address

2373 BROADWAY 1725
NEW YORK NY
10024
US

V. Phone/Fax

Practice location:
  • Phone: 212-923-2525
  • Fax: 646-981-9457
Mailing address:
  • Phone: 212-923-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number041034
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: