Basic Information
| Provider Information | |||||||||
| NPI: | 1619039336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WISSAHICKON AVE STE 118 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2675973600 | ||||||||
| FaxNumber: | 2675973622 | ||||||||
| Practice Location | |||||||||
| Address1: | 6120B WOODLAND AVE #2 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157274721 | ||||||||
| FaxNumber: | 2673505932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2006 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | PADS026092-L | PA | N | Dental Providers | Dentist | General Practice | 1223G0001X | DS026092L | PA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 001135605 | 05 | PA | MEDICAID |