Provider Demographics
NPI:1497177646
Name:MICCHIA, RON
Entity Type:Individual
Prefix:DR
First Name:RON
Middle Name:
Last Name:MICCHIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9140 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-1637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9140 LAKESHORE BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-257-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15919122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist