Healthcare Provider Details

I. General information

NPI: 1245783430
Provider Name (Legal Business Name): MICHAEL LEE MCCUNNIFF DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 SE UNIVERSITY AVE
WAUKEE IA
50263-8933
US

IV. Provider business mailing address

142 SW 2ND ST
CORVALLIS OR
97333-4716
US

V. Phone/Fax

Practice location:
  • Phone: 319-939-4105
  • Fax:
Mailing address:
  • Phone: 888-468-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDDS-09490
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10504
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: