NPIMap

Organization Active NPI

Jack Miceli DDS PC

  • General Practice Dentistry
  • Staten Island, NY
National Provider Identifier
1932266566
Registry record updated Feb 23, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
39067 Issued in NY
Legal business name
JACK MICELI DDS PC
Practice address
255 Mason Ave.
Staten Island, NY 10305-3416
Phone
(718) 987-6543
Fax
(718) 987-6542
NPI assigned
Jan 2, 2007
Organization subpart
Yes
Parent organization
MARINE DENTAL SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 23, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jack Miceli, DDSNPI 1851458483
Title
President
Phone
(718) 987-6543

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X 39067 NY Primary

Addresses

Primary practice location

255 Mason Ave.
Staten Island, NY 10305-3416

Mailing address

255 Mason Ave.
Staten Island, NY 10305-3416
Phone (718) 987-6543

Other identifiers 1

IdentifierTypeStateIssuer
02353280MedicaidNY

Other names 1

  • Marine Dental Services Doing business as

National Provider Directory

National Provider Directory
Part of
Jack Miceli DDS PC

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167696000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1266883200000",
    "number": "1932266566",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "255 MASON AVE.",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103053416",
            "telephone_number": "718-987-6543",
            "fax_number": "718-987-6542"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "255 MASON AVE.",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103053416",
            "telephone_number": "718-987-6543",
            "fax_number": "718-987-6542"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACK MICELI DDS PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MARINE DENTAL SERVICES",
        "enumeration_date": "2007-01-02",
        "last_updated": "2010-02-23",
        "status": "A",
        "authorized_official_last_name": "MICELI",
        "authorized_official_first_name": "JACK",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "718-987-6543",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "NY",
            "license": "39067",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02353280",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Marine Dental Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Staten Island, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 23, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.