MEDICARE: E.A. MITCHELL D.D.S. INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	11041	TX

General Provider Information

NPI Number	:	1073722955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	E.A. MITCHELL D.D.S. INC.

Provider Business Mailing Address
First Line	:	1511 E BERRY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-3005
Country	:	US
Telephone Number	:	817-924-7171
Fax Number	:	817-924-5171

Provider Business Practice Location Address
First Line	:	1511 E BERRY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-3005
Country	:	US
Telephone Number	:	817-924-7171
Fax Number	:	817-924-5171

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. E. A. MITCHELL
Credential	:	D.D.S.
Telephone Number	:	817-924-7171

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	08/22/2020

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