Provider Demographics
NPI:1679198113
Name:MIKEL, GERALD THOMAS
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:THOMAS
Last Name:MIKEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 E PATTISON TOWER RD
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:WI
Mailing Address - Zip Code:54836-9401
Mailing Address - Country:US
Mailing Address - Phone:715-817-2113
Mailing Address - Fax:
Practice Address - Street 1:3312 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5302
Practice Address - Country:US
Practice Address - Phone:715-392-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist