Provider Demographics
NPI:1598330805
Name:MICHAELIS, JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MICHAELIS
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 1:260 DALWILL DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3372
Mailing Address - Country:US
Mailing Address - Phone:985-674-1500
Mailing Address - Fax:
Practice Address - Street 1:260 DALWILL DR
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3372
Practice Address - Country:US
Practice Address - Phone:985-674-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4187-211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty