Provider Demographics
NPI:1861855132
Name:MIRCHEL, THOMAS KELLY LIVINGSTON (DDS,MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:KELLY LIVINGSTON
Last Name:MIRCHEL
Suffix:
Gender:M
Credentials:DDS,MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:292 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4942
Mailing Address - Country:US
Mailing Address - Phone:360-901-1066
Mailing Address - Fax:
Practice Address - Street 1:8101 NE PARKWAY DR STE F2
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-2434
Practice Address - Country:US
Practice Address - Phone:360-882-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-03
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE612511691223S0112X
ORMD210269204E00000X
ORD115911223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty