Provider Demographics
NPI:1124215272
Name:MIKELSON & MIKELSON P.C.
Entity Type:Organization
Organization Name:MIKELSON & MIKELSON P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:MIKELSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-233-6300
Mailing Address - Street 1:3838 W 111TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-4042
Mailing Address - Country:US
Mailing Address - Phone:773-233-6300
Mailing Address - Fax:
Practice Address - Street 1:3838 W 111TH ST STE 105
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-4042
Practice Address - Country:US
Practice Address - Phone:773-233-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty