Provider Demographics
NPI:1346393105
Name:MICKIEWICZ, TIMOTHY E (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:MICKIEWICZ
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 1:930 ALHAMBRA BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4479
Mailing Address - Country:US
Mailing Address - Phone:916-469-9178
Mailing Address - Fax:916-246-0574
Practice Address - Street 1:930 ALHAMBRA BLVD
Practice Address - Street 2:STE 110
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4479
Practice Address - Country:US
Practice Address - Phone:916-469-9178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice