Provider Demographics
NPI:1790099489
Name:HIMMERICH, MICAH DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:DANIEL
Last Name:HIMMERICH
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 1:100 CANYON ROAD
Mailing Address - Street 2:PO BOX 314
Mailing Address - City:DIAMONDVILLE
Mailing Address - State:WY
Mailing Address - Zip Code:83116
Mailing Address - Country:US
Mailing Address - Phone:307-877-6951
Mailing Address - Fax:
Practice Address - Street 1:100 CANYON ROAD
Practice Address - Street 2:
Practice Address - City:DIAMONDVILLE
Practice Address - State:WY
Practice Address - Zip Code:83116
Practice Address - Country:US
Practice Address - Phone:307-877-6951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice