Provider Demographics
NPI:1609941863
Name:MISKOVICH, MIKE N (DDS)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:N
Last Name:MISKOVICH
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 1:1121 SE 4TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-326-3437
Mailing Address - Fax:218-327-1211
Practice Address - Street 1:1121 SE 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-3437
Practice Address - Fax:218-327-1211
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN83131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
85154OtherUNITED CONCORDIA
MN72417MIOtherBLUE CROSS BLUE SH MN