Healthcare Provider Details

I. General information

NPI: 1629075411
Provider Name (Legal Business Name): MICHELE L. MCGORKY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BEVER GRADE ROAD
LAPWAI ID
83540-0367
US

IV. Provider business mailing address

PO DRAWER 367 530 DEMOSS STREET
LAPWAI ID
83540-0367
US

V. Phone/Fax

Practice location:
  • Phone: 208-843-2271
  • Fax: 208-621-4995
Mailing address:
  • Phone: 208-843-2271
  • Fax: 208-621-4995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-4815
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2605
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: