Healthcare Provider Details

I. General information

NPI: 1649530601
Provider Name (Legal Business Name): MITCHELL DOUGLAS DUCKWORTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STONY BROOK UNIVERSITY HOSPITAL DEPT OF
STONY BROOK NY
11794-8711
US

IV. Provider business mailing address

5136 S COTTONWOOD LN
HOLLADAY UT
84117-7102
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2557
  • Fax: 631-444-6013
Mailing address:
  • Phone: 801-718-6395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number8926334-9924
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: