Provider Demographics
NPI:1942422654
Name:MICKLER, JOSEPH BAISDEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:BAISDEN
Last Name:MICKLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4814 SIX FORKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5246
Mailing Address - Country:US
Mailing Address - Phone:919-783-5550
Mailing Address - Fax:919-791-1990
Practice Address - Street 1:2912 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4010
Practice Address - Country:US
Practice Address - Phone:336-765-8941
Practice Address - Fax:336-765-1473
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995944Medicaid