Provider Demographics
NPI:1578640066
Name:MENTOR DENTAL ARTS RONALD L. MICCHIA DDS, INC.
Entity Type:Organization
Organization Name:MENTOR DENTAL ARTS RONALD L. MICCHIA DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MICCHIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-257-3900
Mailing Address - Street 1:9140 LAKESHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060
Mailing Address - Country:US
Mailing Address - Phone:440-257-3900
Mailing Address - Fax:440-257-7070
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:440-257-7070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH159191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty