MEDICARE: DR. MICHAEL LEO MIZELL D.D.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	15069	TX

General Provider Information

NPI Number	:	1306044664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL LEO MIZELL D.D.S.

Provider Business Mailing Address
First Line	:	7700 SAN FELIPE ST STE 250
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77063-1634
Country	:	US
Telephone Number	:	713-781-5548
Fax Number	:	713-781-6876

Provider Business Practice Location Address
First Line	:	7700 SAN FELIPE ST STE 250
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77063-1634
Country	:	US
Telephone Number	:	713-781-5548
Fax Number	:	713-781-6876

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

Provider Enumeration Date	:	07/10/2007
Last Update Date	:	07/10/2007

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