Provider Demographics
NPI:1790450070
Name:MIKOLON, ABIGAIL ROSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ABIGAIL
Middle Name:ROSE
Last Name:MIKOLON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 TOPGOLF WAY APT 5211
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0335
Mailing Address - Country:US
Mailing Address - Phone:570-209-3968
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAL ACTIVITY FORT GORDON ACADEMIC AVE
Practice Address - Street 2:BLDG 38801
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:707-787-5037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043097122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist