Provider Demographics
NPI:1598908428
Name:TICHY, MICHAEL WILLIAM (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:TICHY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2534
Mailing Address - Country:US
Mailing Address - Phone:203-735-7500
Mailing Address - Fax:203-735-0439
Practice Address - Street 1:435 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-2534
Practice Address - Country:US
Practice Address - Phone:203-735-7500
Practice Address - Fax:203-735-0439
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0059311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice