Healthcare Provider Details

I. General information

NPI: 1801968839
Provider Name (Legal Business Name): ANTHONY CHARLES MICHELICH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 VIKING DR NW
ROCHESTER MN
55901-3522
US

IV. Provider business mailing address

1408 WILSHIRE WOODS LN NE
ROCHESTER MN
55906-6917
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-1338
  • Fax:
Mailing address:
  • Phone: 507-281-8199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number07829
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: