MEDICARE: MARY E. MIKELSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019019681	IL

General Provider Information

NPI Number	:	1477841583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY E. MIKELSON DDS

Provider Business Mailing Address
First Line	:	3838 W 111TH ST STE 105
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-4042
Country	:	US
Telephone Number	:	773-233-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	3838 W 111TH ST STE 105
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-4042
Country	:	US
Telephone Number	:	773-233-6300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2011
Last Update Date	:	07/11/2011

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