1568795649 NPI number — MICKELWAIT FAMILY DENTISTRY PLLC

Table of content: (NPI 1568795649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568795649 NPI number — MICKELWAIT FAMILY DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICKELWAIT FAMILY DENTISTRY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568795649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 ROOSEVELT AVE
Provider Second Line Business Mailing Address:
STE 7
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98273-2687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-424-3450
Provider Business Mailing Address Fax Number:
360-428-0927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 ROOSEVELT AVE
Provider Second Line Business Practice Location Address:
STE 7
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273-2687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-424-3450
Provider Business Practice Location Address Fax Number:
360-428-0927
Provider Enumeration Date:
09/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MICKELWAIT
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
360-424-3450

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DE60070169 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com