Basic Information
| Provider Information | |||||||||
| NPI: | 1376703785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKESELL | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D. D. S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 329 N WEST ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192213072 | ||||||||
| FaxNumber: | 4195495671 | ||||||||
| Practice Location | |||||||||
| Address1: | 441 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192213072 | ||||||||
| FaxNumber: | 4195498257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 05/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | 30-021456 | OH | Y | Dental Providers | Dentist | Endodontics |
ID Information
| ID | Type | State | Issuer | Description | 2835034 | 05 | OH | MEDICAID |