Provider Demographics
NPI:1376519181
Name:KOLODYCHAK, MICHAEL THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:KOLODYCHAK
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 1:4600 ZUCK RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4932
Mailing Address - Country:US
Mailing Address - Phone:814-838-2144
Mailing Address - Fax:814-838-7227
Practice Address - Street 1:4600 ZUCK RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4932
Practice Address - Country:US
Practice Address - Phone:814-838-2144
Practice Address - Fax:814-838-7227
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029985L1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS029985LOtherSTATE LICENSE
PADS029985LOtherSTATE LICENSE