Provider Demographics
NPI:1255407250
Name:MIKKELSON, RONALD A (DDS)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:A
Last Name:MIKKELSON
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 1:140 N PERCIVAL SUITE B
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5438
Mailing Address - Country:US
Mailing Address - Phone:360-754-4949
Mailing Address - Fax:360-754-4948
Practice Address - Street 1:140 N PERCIVAL SUITE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5438
Practice Address - Country:US
Practice Address - Phone:360-754-4949
Practice Address - Fax:360-754-4948
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist