Provider Demographics
NPI:1063542009
Name:MICOLI, RICHARD A (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:MICOLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6780 PITTSFORD PALMYRA RD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3360
Mailing Address - Country:US
Mailing Address - Phone:585-223-2888
Mailing Address - Fax:585-223-0009
Practice Address - Street 1:6780 PITTSFORD PALMYRA RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3360
Practice Address - Country:US
Practice Address - Phone:585-223-2888
Practice Address - Fax:585-223-0009
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice