MEDICARE: DR. JOHN EDWARD MICELI D.M.D.

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	DS-030548-L	PA
2	1223G0001X	General Practice Dentistry	12971	MD
3	1223G0001X	General Practice Dentistry	30.021870	OH

General Provider Information

NPI Number	:	1982780862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN EDWARD MICELI D.M.D.

Provider Business Mailing Address
First Line	:	944 AURORA AVE
Second Line	:
City	:	GIRARD
State	:	PA
Zip	:	16417-1246
Country	:	US
Telephone Number	:	814-774-1498
Fax Number	:	814-774-5242

Provider Business Practice Location Address
First Line	:	9984 MARTIN AVE
Second Line	:
City	:	LAKE CITY
State	:	PA
Zip	:	16423-1527
Country	:	US
Telephone Number	:	814-774-5242
Fax Number	:	814-774-5242

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

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/08/2007

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