Provider Demographics
NPI:1477841583
Name:MIKELSON, MARY E (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MIKELSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 W 111TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-4042
Mailing Address - Country:US
Mailing Address - Phone:773-233-6300
Mailing Address - Fax:
Practice Address - Street 1:3838 W 111TH ST STE 105
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-4042
Practice Address - Country:US
Practice Address - Phone:773-233-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190196811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice