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General NPI Number Information
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NPI Number | 1801918255
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Entity Type | Organization
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Legal Business Name | KENNETH G MIZE DMDPC
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Dates
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Enumeration Date | 04/05/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 411 W MAIN ST
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City | SHERIDAN
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State | OR
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Zip | 97378-1117
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Country | US
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Telephone | 503-843-4433
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Fax | 503-843-4434
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Provider Business Mailing Address
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Address Line | 411 W MAIN ST P.O. BOX 100
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City | SHERIDAN
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State | OR
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Zip | 97378-1117
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Country | US
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Telephone | 503-843-4433
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Fax | 503-843-4434
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Authorized Official
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Title or Position | PRESIDENT
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Name | KENNETH G MIZE
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Credential | DMD
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Telephone | 503-843-4433
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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 | D5811
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License Number State | OR
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