Provider Demographics
NPI:1053442376
Name:MCDONALD, MICA (RDH)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 EMERALD TRACE WAY
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-6951
Mailing Address - Country:US
Mailing Address - Phone:817-808-5754
Mailing Address - Fax:
Practice Address - Street 1:331 W HARWOOD RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3047
Practice Address - Country:US
Practice Address - Phone:817-282-4539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11329124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist