Provider Demographics
NPI:1932266566
Name:JACK MICELI DDS PC
Entity Type:Organization
Organization Name:JACK MICELI DDS PC
Other - Org Name:MARINE DENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:MICELI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-987-6543
Mailing Address - Street 1:255 MASON AVE.
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3416
Mailing Address - Country:US
Mailing Address - Phone:718-987-6543
Mailing Address - Fax:718-987-6542
Practice Address - Street 1:255 MASON AVE.
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3416
Practice Address - Country:US
Practice Address - Phone:718-987-6543
Practice Address - Fax:718-987-6542
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARINE DENTAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02353280Medicaid