Healthcare Provider Details

I. General information

NPI: 1740457332
Provider Name (Legal Business Name): MICHAEL G. SUMMERS DDS, MS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 CALL CREEK SUITE B
POCATELLO ID
83202
US

IV. Provider business mailing address

1133 CALL CREEK SUITE B
POCATELLO ID
83202
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: DR. MICHAEL G. SUMMERS
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 208-232-0464