Healthcare Provider Details

I. General information

NPI: 1013021575
Provider Name (Legal Business Name): MICHAEL J. MCCALL D.D.S., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 MAIN STREET
KAMIAH ID
83536
US

IV. Provider business mailing address

306 MAIN STREET P.O. BOX 458
KAMIAH ID
83536
US

V. Phone/Fax

Practice location:
  • Phone: 208-935-2143
  • Fax:
Mailing address:
  • Phone: 208-935-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberC128433
License Number StateID

VIII. Authorized Official

Name: DR. MICHAEL JAMES MCCALL
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 208-935-2143