Healthcare Provider Details

I. General information

NPI: 1891727582
Provider Name (Legal Business Name): MICHAEL R BAILEY M.D., D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 SOUTH 11TH STREET SUITE 300
BOISE ID
83702-6906
US

IV. Provider business mailing address

403 SOUTH 11TH STREET SUITE 300
BOISE ID
83702-6906
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-9115
  • Fax: 208-344-9113
Mailing address:
  • Phone: 208-344-9115
  • Fax: 208-344-9113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD3165
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: