Healthcare Provider Details

I. General information

NPI: 1356892657
Provider Name (Legal Business Name): THOMAS R. MICHAELIS, D.D.S., M.D., INC, RYAN M. KRIWANEK, D.D.S., M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AVOCADO AVE. SUITE 506
NEWPORT BEACH CA
92660
US

IV. Provider business mailing address

1401 AVOCADO AVE. SUITE 506
NEWPORT BEACH CA
92660
US

V. Phone/Fax

Practice location:
  • Phone: 949-760-1661
  • Fax: 949-760-8016
Mailing address:
  • Phone: 949-760-1661
  • Fax: 949-760-8016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22313
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number38855
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number42745
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number58948
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS RAYMOND MICHAELIS
Title or Position: PARTNER
Credential: DDS, MD
Phone: 949-760-1661