Provider Demographics
NPI:1851458483
Name:MICELI, JACK (DDS)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:MICELI
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 1:255 MASON AVE.
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3416
Mailing Address - Country:US
Mailing Address - Phone:718-987-6543
Mailing Address - Fax:718-987-6542
Practice Address - Street 1:255 MASON AVE.
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3416
Practice Address - Country:US
Practice Address - Phone:718-987-6543
Practice Address - Fax:718-987-6542
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02241885Medicaid