Provider Demographics
NPI:1083738926
Name:MICHIKO MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MICHIKO MANAGEMENT, LLC
Other - Org Name:BROOKSTONE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:480-231-7020
Mailing Address - Street 1:16421 N TATUM BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3454
Mailing Address - Country:US
Mailing Address - Phone:602-992-1639
Mailing Address - Fax:602-992-9601
Practice Address - Street 1:3509 E ROCKY SLOPE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-7094
Practice Address - Country:US
Practice Address - Phone:480-231-7020
Practice Address - Fax:480-704-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty