Provider Demographics
NPI:1760897714
Name:MICKLES, ALICIA JAMELLE (DDS)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:JAMELLE
Last Name:MICKLES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26000 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-1110
Mailing Address - Country:US
Mailing Address - Phone:216-289-0890
Mailing Address - Fax:
Practice Address - Street 1:26000 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-1110
Practice Address - Country:US
Practice Address - Phone:216-289-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-29
Last Update Date:2020-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11769122300000X
TN10030122300000X
390200000X
OH30.025418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program