MEDICARE: MIKELSON & MIKELSON P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		IL

General Provider Information

NPI Number	:	1124215272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIKELSON & MIKELSON P.C.

Provider Business Mailing Address
First Line	:	3838 W 111TH ST STE 105
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-4042
Country	:	US
Telephone Number	:	773-233-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	3838 W 111TH ST STE 105
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-4042
Country	:	US
Telephone Number	:	773-233-6300
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT C. MIKELSON JR.
Credential	:	D.D.S.
Telephone Number	:	773-233-6300

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/02/2007

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