Provider Demographics
NPI:1144293457
Name:MITCHELL, JAMIE ALAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:ALAN
Last Name:MITCHELL
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:PO BOX 229
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:GA
Mailing Address - Zip Code:31064
Mailing Address - Country:US
Mailing Address - Phone:706-468-6394
Mailing Address - Fax:706-468-8113
Practice Address - Street 1:458 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064
Practice Address - Country:US
Practice Address - Phone:706-468-6394
Practice Address - Fax:706-468-8113
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA109121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00429591AMedicaid