Provider Demographics
NPI:1376703785
Name:MIKESELL, PHILIP B (D D S)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:B
Last Name:MIKESELL
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4332
Mailing Address - Country:US
Mailing Address - Phone:419-221-3072
Mailing Address - Fax:419-549-5671
Practice Address - Street 1:441 E 8TH ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2482
Practice Address - Country:US
Practice Address - Phone:419-221-3072
Practice Address - Fax:419-549-8257
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0214561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2835034Medicaid