Provider Demographics
NPI:1043489610
Name:MIKOLICH, MARISSA
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:MIKOLICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5875 LANDERBROOK DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-6511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 BELDEN VILLAGE MALL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2502
Practice Address - Country:US
Practice Address - Phone:330-494-7051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0220311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics