Provider Demographics
NPI:1912997735
Name:MIKUS, MARK A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MIKUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 CREEKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-3371
Mailing Address - Country:US
Mailing Address - Phone:724-772-3209
Mailing Address - Fax:412-369-7433
Practice Address - Street 1:9400 MCKNIGHT RD STE 101
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-6007
Practice Address - Country:US
Practice Address - Phone:412-369-7122
Practice Address - Fax:412-369-7433
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031540L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021208600001Medicaid