Healthcare Provider Details

I. General information

NPI: 1720320377
Provider Name (Legal Business Name): DR. MICKEY'S ORTHODONTICS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 MONTVALE AVE SUITE 4300
STONEHAM MA
02180-3647
US

IV. Provider business mailing address

92 MONTVALE AVE SUITE 4300
STONEHAM MA
02180-3647
US

V. Phone/Fax

Practice location:
  • Phone: 781-279-2400
  • Fax:
Mailing address:
  • Phone: 781-279-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN20656
License Number StateMA

VIII. Authorized Official

Name: DR. EUGENE A MICKEY
Title or Position: PRESIDENT/OWNER
Credential: DMD
Phone: 781-279-2400