Provider Demographics
NPI:1568795649
Name:MICKELWAIT FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:MICKELWAIT FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MICKELWAIT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-424-3450
Mailing Address - Street 1:1420 ROOSEVELT AVE
Mailing Address - Street 2:STE 7
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2687
Mailing Address - Country:US
Mailing Address - Phone:360-424-3450
Mailing Address - Fax:360-428-0927
Practice Address - Street 1:1420 ROOSEVELT AVE
Practice Address - Street 2:STE 7
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2687
Practice Address - Country:US
Practice Address - Phone:360-424-3450
Practice Address - Fax:360-428-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60070169122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty