Healthcare Provider Details

I. General information

NPI: 1902168271
Provider Name (Legal Business Name): DAVID E MIKA II D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 107
PERRY MI
48872-0107
US

IV. Provider business mailing address

PO BOX 107
PERRY MI
48872-0107
US

V. Phone/Fax

Practice location:
  • Phone: 517-625-5552
  • Fax:
Mailing address:
  • Phone: 517-625-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901020672
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901020672
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: