Healthcare Provider Details

I. General information

NPI: 1598989840
Provider Name (Legal Business Name): MICHAEL G. SUMMERS D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 CALL CREEK DR.
POCATELLO ID
83201-3000
US

IV. Provider business mailing address

1133 CALL CREEK DR.
POCATELLO ID
83201-3000
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-0464
  • Fax: 208-232-0863
Mailing address:
  • Phone: 208-232-0464
  • Fax: 208-232-0863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-3284-OR
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: