Provider Demographics
NPI:1134209513
Name:MINICHELLI, MARK RICHARD (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:MINICHELLI
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 1:2606 CAUGHEY RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-2148
Mailing Address - Country:US
Mailing Address - Phone:814-833-4393
Mailing Address - Fax:814-838-0781
Practice Address - Street 1:2606 CAUGHEY RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-2148
Practice Address - Country:US
Practice Address - Phone:814-833-4393
Practice Address - Fax:814-838-0781
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027249L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA608515OtherUNITED CONCORDIA PROVIDER