Basic Information
| Provider Information | |||||||||
| NPI: | 1992827877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKESELL | ||||||||
| FirstName: | LEO | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO DRAWER PH | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747001 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Practice Location | |||||||||
| Address1: | HWY 191 HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747001 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 1223S0112X | 133643-9923 | UT | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 824624 | 05 | AZ | MEDICAID |