Healthcare Provider Details

I. General information

NPI: 1477674653
Provider Name (Legal Business Name): SAMUEL BRADLEY MIZE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 FOREST XING SUITE G
THE WOODLANDS TX
77381-1180
US

IV. Provider business mailing address

9001 FOREST XING SUITE G
THE WOODLANDS TX
77381-1180
US

V. Phone/Fax

Practice location:
  • Phone: 281-681-0100
  • Fax: 281-419-6155
Mailing address:
  • Phone: 281-681-0100
  • Fax: 281-419-6155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number17657
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: