Provider Demographics
NPI:1356892657
Name:THOMAS R. MICHAELIS, D.D.S., M.D., INC, RYAN M. KRIWANEK, D.D.S., M.D.
Entity type:Organization
Organization Name:THOMAS R. MICHAELIS, D.D.S., M.D., INC, RYAN M. KRIWANEK, D.D.S., M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:MICHAELIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:949-760-1661
Mailing Address - Street 1:1401 AVOCADO AVE. SUITE 506
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-760-1661
Mailing Address - Fax:949-760-8016
Practice Address - Street 1:1401 AVOCADO AVE. SUITE 506
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-760-1661
Practice Address - Fax:949-760-8016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA223131223S0112X
CA427451223S0112X
CA589481223S0112X
204E00000X
CA388551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty