Healthcare Provider Details

I. General information

NPI: 1023477312
Provider Name (Legal Business Name): MIKA ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N. MAIN ST.
PERRY MI
48872
US

IV. Provider business mailing address

PO BOX 107
PERRY MI
48872
US

V. Phone/Fax

Practice location:
  • Phone: 517-625-5552
  • Fax: 517-625-5049
Mailing address:
  • Phone: 517-625-5552
  • Fax: 517-625-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901020672
License Number StateMI

VIII. Authorized Official

Name: MRS. SHURON RENEE HOLDER
Title or Position: OFFICE MANAGER
Credential:
Phone: 517-625-5552