Provider Demographics
NPI:1205271970
Name:MICKELWAIT, KRISSA ANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISSA
Middle Name:ANNE
Last Name:MICKELWAIT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14206 COVE CT
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98232-8589
Mailing Address - Country:US
Mailing Address - Phone:360-708-7664
Mailing Address - Fax:
Practice Address - Street 1:220 UNITY ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4429
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60363231122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist