Healthcare Provider Details

I. General information

NPI: 1376703785
Provider Name (Legal Business Name): PHILIP B. MIKESELL D. D. S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 E 8TH ST
LIMA OH
45804-2482
US

IV. Provider business mailing address

329 N WEST ST
LIMA OH
45801-4332
US

V. Phone/Fax

Practice location:
  • Phone: 419-221-3072
  • Fax: 419-549-8257
Mailing address:
  • Phone: 419-221-3072
  • Fax: 419-549-5671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number30-021456
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2835034
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: