Provider Demographics
NPI:1902048754
Name:MISENCIK, MICHAEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:MISENCIK
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 1:1205 CANYON VIEW RD
Mailing Address - Street 2:
Mailing Address - City:SAGAMORE HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44067
Mailing Address - Country:US
Mailing Address - Phone:216-688-6349
Mailing Address - Fax:
Practice Address - Street 1:109 HARRIS ROAD
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254
Practice Address - Country:US
Practice Address - Phone:330-302-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH018257122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0666097Medicaid