Provider Demographics
NPI:1275675902
Name:MIKOWICZ, EDWARD M (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:MIKOWICZ
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 1:112 SOUTH B ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-2354
Mailing Address - Country:US
Mailing Address - Phone:805-736-6571
Mailing Address - Fax:805-737-5663
Practice Address - Street 1:112 SOUTH B ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2354
Practice Address - Country:US
Practice Address - Phone:805-736-6571
Practice Address - Fax:805-737-5663
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA274581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice