Provider Demographics
NPI:1851461115
Name:MITCHELL, JANE ELLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:JANE
Middle Name:ELLEN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 PURDUE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3624
Mailing Address - Country:US
Mailing Address - Phone:347-721-5324
Mailing Address - Fax:
Practice Address - Street 1:1801 PURDUE DR STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3624
Practice Address - Country:US
Practice Address - Phone:347-721-5324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033927122300000X
NC93881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00725897Medicaid