Individual
MR. JACK MICELI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
255 MASON AVE., STATEN ISLAND, NY 10305-3416
(718) 987-6543
(718) 987-6542
Mailing address
255 MASON AVE., STATEN ISLAND, NY 10305-3416
(718) 987-6543
(718) 987-6542
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
39067
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02241885
—
NY
Enumeration date
01/02/2007
Last updated
02/23/2010
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