Healthcare Provider Details

I. General information

NPI: 1861645202
Provider Name (Legal Business Name): MICHAEL VERLYN DABELL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 N CRESTMONT DR STE G
MERIDIAN ID
83642-2177
US

IV. Provider business mailing address

1550 N CRESTMONT DR STE G
MERIDIAN ID
83642-2177
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-0100
  • Fax: 208-884-4844
Mailing address:
  • Phone: 208-884-0100
  • Fax: 208-884-4844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDR 60035396
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-4099-OS
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: