Provider Demographics
NPI:1154419620
Name:MIXON, KRISTOPHER G (DMD)
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:G
Last Name:MIXON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3432 MERCER UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-4902
Mailing Address - Country:US
Mailing Address - Phone:478-755-8366
Mailing Address - Fax:478-755-8399
Practice Address - Street 1:3432 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-4902
Practice Address - Country:US
Practice Address - Phone:478-755-8366
Practice Address - Fax:478-755-8399
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA130001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice