Healthcare Provider Details

I. General information

NPI: 1811537251
Provider Name (Legal Business Name): MICKELSON-GATES DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 N MERRITT CREEK
COEUR D ALENE ID
83814-8381
US

IV. Provider business mailing address

2165 N MERRITT CREEK LOOP
COEUR D ALENE ID
83814-4949
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-8282
  • Fax:
Mailing address:
  • Phone: 208-667-8282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: AMY WINTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-667-8282