MEDICARE: GRIFFIN E MIZELL JR. 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	1223G0001X	General Practice Dentistry	9762	GA

General Provider Information

NPI Number	:	1699791756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRIFFIN E MIZELL JR. D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 128
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-0128
Country	:	US
Telephone Number	:	229-868-6615
Fax Number	:	229-868-6615

Provider Business Practice Location Address
First Line	:	100 W PARSONAGE ST
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-1735
Country	:	US
Telephone Number	:	229-868-6615
Fax Number	:	229-868-6615

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/08/2007

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Directions to “ GRIFFIN E MIZELL JR. D.D.S.” Practice Location

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