Provider Demographics
NPI:1316327414
Name:COLE, MICKEY (RDH)
Entity type:Individual
Prefix:
First Name:MICKEY
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 COUNTY ROAD 83
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:CA
Mailing Address - Zip Code:96015
Mailing Address - Country:US
Mailing Address - Phone:530-233-4641
Mailing Address - Fax:530-708-8940
Practice Address - Street 1:670 COUNTY ROAD 83
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:CA
Practice Address - Zip Code:96015
Practice Address - Country:US
Practice Address - Phone:530-233-4641
Practice Address - Fax:530-708-8940
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15034124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist