MEDICARE: MICKELWAIT FAMILY DENTISTRY PLLC

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	122300000X	Dentist	DE60070169	WA

General Provider Information

NPI Number	:	1568795649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICKELWAIT FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	1420 ROOSEVELT AVE
Second Line	:	STE 7
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-2687
Country	:	US
Telephone Number	:	360-424-3450
Fax Number	:	360-428-0927

Provider Business Practice Location Address
First Line	:	1420 ROOSEVELT AVE
Second Line	:	STE 7
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-2687
Country	:	US
Telephone Number	:	360-424-3450
Fax Number	:	360-428-0927

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. JOEL S MICKELWAIT
Credential	:	D.D.S.
Telephone Number	:	360-424-3450

Provider Enumeration Date	:	09/08/2009
Last Update Date	:	09/08/2009

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