Healthcare Provider Details

I. General information

NPI: 1346502465
Provider Name (Legal Business Name): MICHELLE PRATHER D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35TH MEDICAL GROUP - MISAWA AIR BASE UNIT 5024, BUILDING 99
APO AP
96319
US

IV. Provider business mailing address

35TH MEDICAL GROUP - MISAWA AIR BASE UNIT 5024, BUILDING 99
APO AP
96319
US

V. Phone/Fax

Practice location:
  • Phone: 618-960-9065
  • Fax:
Mailing address:
  • Phone: 618-960-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.028636
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: