Provider Demographics
NPI:1992827877
Name:MIKESELL, LEO V (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:V
Last Name:MIKESELL
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:PO DRAWER PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503
Mailing Address - Country:US
Mailing Address - Phone:928-674-7001
Mailing Address - Fax:928-674-7705
Practice Address - Street 1:HWY 191 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7001
Practice Address - Fax:928-674-7705
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT133643-99231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ824624Medicaid
AZT77955Medicare UPIN
AZ8HC177Medicare ID - Type UnspecifiedMEDICARE PART B - CHINLE