MEDICARE: DR. KASSONDRA ANN MICHNO DMD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	12265	NC

General Provider Information

NPI Number	:	1881278679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KASSONDRA ANN MICHNO DMD

Provider Business Mailing Address
First Line	:	826 HOMESTEAD DR
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-7227
Country	:	US
Telephone Number	:	570-332-1911
Fax Number	:

Provider Business Practice Location Address
First Line	:	1280 WESTERN BLVD UNIT 200
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-7658
Country	:	US
Telephone Number	:	910-388-0223
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2021
Last Update Date	:	06/11/2021

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