MEDICARE: DR. EVAN MITCHELL DDS

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	122300000X	Dentist	DB-2023-0212	NM
2	122300000X	Dentist	DE60874699	WA

General Provider Information

NPI Number	:	1194202051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVAN MITCHELL DDS

Provider Business Mailing Address
First Line	:	2600 THE AMERICAN RD SE STE 369
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-1858
Country	:	US
Telephone Number	:	505-898-6000
Fax Number	:	505-898-6166

Provider Business Practice Location Address
First Line	:	2600 THE AMERICAN RD SE STE 369
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-1858
Country	:	US
Telephone Number	:	505-898-6000
Fax Number	:	505-890-6166

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2018
Last Update Date	:	12/14/2023

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