Provider Demographics
NPI:1083700793
Name:ICASIANO, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ICASIANO
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 1:7101 HOFF ST. BLDG 9240
Mailing Address - Street 2:USA DENTAL ACTIVITY
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:706-544-4530
Mailing Address - Fax:706-544-1933
Practice Address - Street 1:7101 HOFF ST. BLDG 9240
Practice Address - Street 2:USA DENTAL ACTIVITY
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-544-4530
Practice Address - Fax:706-544-1933
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029194L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery