Provider Demographics
NPI:1164614061
Name:MICKA, JOHN F (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:F
Last Name:MICKA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1814
Mailing Address - Country:US
Mailing Address - Phone:630-584-6177
Mailing Address - Fax:630-584-8504
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1814
Practice Address - Country:US
Practice Address - Phone:630-584-6177
Practice Address - Fax:630-584-8504
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist