Provider Demographics
NPI:1649352501
Name:MICHELICH, PETER LOUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:LOUIS
Last Name:MICHELICH
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 1:4000 ANNAPOLIS LN N
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5480
Mailing Address - Country:US
Mailing Address - Phone:763-551-0501
Mailing Address - Fax:612-573-6687
Practice Address - Street 1:4000 ANNAPOLIS LN N
Practice Address - Street 2:SUITE 103
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5480
Practice Address - Country:US
Practice Address - Phone:763-551-0501
Practice Address - Fax:612-573-6687
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND71151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice