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General NPI Number Information
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NPI Number | 1073637930
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Entity Type | Individual
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Provider Name | STACIE MAXIMIEK MITCHELL DMD
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Gender | Female
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Dates
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Enumeration Date | 03/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 310 PINE ST
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City | DANVILLE
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State | PA
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Zip | 17821-1956
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Country | US
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Telephone | 570-275-2600
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Fax |
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Provider Business Mailing Address
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Address Line | 5 HILLSIDE DR
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City | BLOOMSBURG
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State | PA
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Zip | 17815-7722
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Country | US
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Telephone | 570-387-8680
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS035256
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License Number State | PA
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