Provider Demographics
NPI:1699791756
Name:MIZELL, GRIFFIN E JR (DDS)
Entity type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:E
Last Name:MIZELL
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:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:MC RAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055-0128
Mailing Address - Country:US
Mailing Address - Phone:229-868-6615
Mailing Address - Fax:229-868-6615
Practice Address - Street 1:100 W PARSONAGE ST
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055-1735
Practice Address - Country:US
Practice Address - Phone:229-868-6615
Practice Address - Fax:229-868-6615
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA97621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice