Provider Demographics
NPI:1275677452
Name:MINICHELLI DENTISTRY, INC.
Entity Type:Organization
Organization Name:MINICHELLI DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MINICHELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:814-833-4393
Mailing Address - Street 1:2606 CAUGHEY RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-2148
Mailing Address - Country:US
Mailing Address - Phone:814-833-4393
Mailing Address - Fax:814-838-0781
Practice Address - Street 1:2606 CAUGHEY RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-2148
Practice Address - Country:US
Practice Address - Phone:814-833-4393
Practice Address - Fax:814-838-0781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027249L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA608515OtherUCCI