Provider Demographics
NPI:1720320377
Name:DR. MICKEY'S ORTHODONTICS, L.L.C.
Entity Type:Organization
Organization Name:DR. MICKEY'S ORTHODONTICS, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-279-2400
Mailing Address - Street 1:92 MONTVALE AVE
Mailing Address - Street 2:SUITE 4300
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3647
Mailing Address - Country:US
Mailing Address - Phone:781-279-2400
Mailing Address - Fax:
Practice Address - Street 1:92 MONTVALE AVE
Practice Address - Street 2:SUITE 4300
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3647
Practice Address - Country:US
Practice Address - Phone:781-279-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EUGENE A MICKEY, DMD, MPH, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN206561223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty