Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 11473 | MA |
NPI | 1003030982 |
---|---|
Provider Name | Dr. John D Mitsch |
First Address | Weymouth, MA 02188-2337 |
Second Address | Weymouth, MA 02188-2337 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0110 | DELTA DENTAL (01) | MA |
821971 | UNITED CONCORDIA (01) | MA |
X11032 | BLUE CROSS BLUE SHIELD (01) | MA |