=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710029442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARD M. MIKOWICZ D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 SOUTH B ST.
-----------------------------------------------------
City | LOMPOC
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-736-6571
-----------------------------------------------------
Fax | 805-737-5663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 SOUTH B ST.
-----------------------------------------------------
City | LOMPOC
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-736-6571
-----------------------------------------------------
Fax | 805-737-5663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EDWARD M. MIKOWICZ
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 805-736-6571
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 27458
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------