Healthcare Provider Details

I. General information

NPI: 1295929164
Provider Name (Legal Business Name): MICHAEL EDWARD MILEWSKI D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6404 ROOSEVELT BLVD SUITE 4
PHILADELPHIA PA
19149-2943
US

IV. Provider business mailing address

417 SHAWMONT AVE UNIT C
PHILADELPHIA PA
19128-4043
US

V. Phone/Fax

Practice location:
  • Phone: 215-743-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS037254
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS037254
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: