Provider Demographics
NPI:1699887976
Name:MITCHELL, STEPHEN GLENN (DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GLENN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1750 POWDER SPRINGS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064
Mailing Address - Country:US
Mailing Address - Phone:770-499-1304
Mailing Address - Fax:770-499-1308
Practice Address - Street 1:1750 POWDER SPRINGS RD
Practice Address - Street 2:SUITE 520
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
Practice Address - Country:US
Practice Address - Phone:770-499-1304
Practice Address - Fax:770-499-1308
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA9650122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00507691BMedicaid