Provider Demographics
NPI:1952380974
Name:MIKESELL, THOR L (DDS)
Entity type:Individual
Prefix:
First Name:THOR
Middle Name:L
Last Name:MIKESELL
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:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-0759
Mailing Address - Country:US
Mailing Address - Phone:231-271-3315
Mailing Address - Fax:231-271-3317
Practice Address - Street 1:408 ST JOSEPH ST
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682
Practice Address - Country:US
Practice Address - Phone:231-271-3315
Practice Address - Fax:231-271-3317
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist