Provider Demographics
NPI:1154531820
Name:MITCHELL, CARL STANLEY JR (DDS)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:STANLEY
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 CLEVELAND AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344
Mailing Address - Country:US
Mailing Address - Phone:404-766-4386
Mailing Address - Fax:
Practice Address - Street 1:1136 CLEVELAND AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3618
Practice Address - Country:US
Practice Address - Phone:404-766-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN009761122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist