Provider Demographics
NPI:1538388517
Name:MICK, TERRY JEAN (DMD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:JEAN
Last Name:MICK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 NORTH MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351
Mailing Address - Country:US
Mailing Address - Phone:850-627-9661
Mailing Address - Fax:850-627-9324
Practice Address - Street 1:315 NORTH MADISON STREET
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351
Practice Address - Country:US
Practice Address - Phone:850-627-9661
Practice Address - Fax:850-627-9324
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist