Healthcare Provider Details

I. General information

NPI: 1215778246
Provider Name (Legal Business Name): MIKAELA ANN-MARIE MITCHELL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3891 UNIVERSITY TOWN CENTRE DR
MORGANTOWN WV
26501-2432
US

IV. Provider business mailing address

248 COTTONTAIL DR
MORGANTOWN WV
26508-1663
US

V. Phone/Fax

Practice location:
  • Phone: 304-212-3070
  • Fax:
Mailing address:
  • Phone: 304-685-3359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4703
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: