=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720320377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. MICKEY'S ORTHODONTICS, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2013
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 92 MONTVALE AVE SUITE 4300
-----------------------------------------------------
City | STONEHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02180-3647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-279-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 92 MONTVALE AVE SUITE 4300
-----------------------------------------------------
City | STONEHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02180-3647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-279-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. EUGENE A MICKEY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 781-279-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN20656
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------