Provider Demographics
NPI:1497365134
Name:MIKKALSON, LAYTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAYTON
Middle Name:
Last Name:MIKKALSON
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:COMMANDING OFFICER, 2D DENBN/NDC, PSC 20130
Mailing Address - Street 2:315 MCHUGH BLVD
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0130
Mailing Address - Country:US
Mailing Address - Phone:910-451-2208
Mailing Address - Fax:910-451-8479
Practice Address - Street 1:COMMANDING OFFICER, 2D DENBN/NDC, PSC 20130
Practice Address - Street 2:315 MCHUGH BLVD
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0130
Practice Address - Country:US
Practice Address - Phone:910-451-2208
Practice Address - Fax:910-451-8479
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14449122300000X
NC12298122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist