Organization
JACK MICELI DDS PC
Active
Parent organization
MARINE DENTAL SERVICES
Other names
Marine Dental Services
Organization subpart
Yes
Provider details
NPI number
Legal business name
MARINE DENTAL SERVICES
Authorized official
MR. JACK MICELI DDS (PRESIDENT)
(718) 987-6543
Entity
Organization
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
—
02353280
—
NY
Enumeration date
01/02/2007
Last updated
02/23/2010
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