Provider Demographics
NPI:1184641136
Name:MIKELS, GARY H (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:H
Last Name:MIKELS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 NORTH PEARL ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-584-6070
Mailing Address - Fax:508-275-3935
Practice Address - Street 1:348 NORTH PEARL ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-584-6070
Practice Address - Fax:508-275-3935
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13897122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0251992Medicaid