Provider Demographics
NPI:1699430041
Name:MICKELSON, KYRA (RDH)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:MICKELSON
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 1:4192 6TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-1260
Mailing Address - Country:US
Mailing Address - Phone:928-679-5898
Mailing Address - Fax:
Practice Address - Street 1:4192 6TH ST APT 4
Practice Address - Street 2:
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-1260
Practice Address - Country:US
Practice Address - Phone:928-679-5898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK147040124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist