Provider Demographics
NPI:1982685855
Name:MIKA, JOSEPH A (DDS,LLC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:MIKA
Suffix:
Gender:M
Credentials:DDS,LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 MARKET ST STE 6
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-2915
Mailing Address - Country:US
Mailing Address - Phone:330-758-2156
Mailing Address - Fax:330-758-7274
Practice Address - Street 1:5815 MARKET ST STE 6
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-2915
Practice Address - Country:US
Practice Address - Phone:330-758-2156
Practice Address - Fax:330-758-7274
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-94391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0916594Medicaid
OH30-01-9439OtherOHIO DENTIST LICENSE
OHU40510Medicare UPIN