MEDICARE: DR. SHELLY MIXSON

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	012436	GA

General Provider Information

NPI Number	:	1952467425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHELLY MIXSON

Provider Business Mailing Address
First Line	:	1133 E WEST CONNECTOR
Second Line	:	STE. 120 & 130
City	:	AUSTELL
State	:	GA
Zip	:	30106-1589
Country	:	US
Telephone Number	:	770-333-9951
Fax Number	:	770-333-9953

Provider Business Practice Location Address
First Line	:	3528 ASHFORD DUNWOODY ROAD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30319
Country	:	US
Telephone Number	:	770-455-6602
Fax Number	:

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

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	05/20/2021

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