Provider Demographics
NPI:1922015221
Name:MIKULICZ, JOSEPH ROBERT (DMD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ROBERT
Last Name:MIKULICZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 N ALMA SCHOOL RD
Mailing Address - Street 2:STE 22
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224
Mailing Address - Country:US
Mailing Address - Phone:480-821-8295
Mailing Address - Fax:480-821-8268
Practice Address - Street 1:312 N ALMA SCHOOL RD
Practice Address - Street 2:STE 22
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-821-8295
Practice Address - Fax:480-821-8268
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4519122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist