Healthcare Provider Details

I. General information

NPI: 1841276466
Provider Name (Legal Business Name): JONATHAN MICHELSOHN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 PARK AVE
CRANSTON RI
02910-2036
US

IV. Provider business mailing address

795 PARK AVE
CRANSTON RI
02910-2036
US

V. Phone/Fax

Practice location:
  • Phone: 401-781-2212
  • Fax: 401-461-3408
Mailing address:
  • Phone: 401-781-2212
  • Fax: 401-461-3408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2281
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: