Healthcare Provider Details

I. General information

NPI: 1063504819
Provider Name (Legal Business Name): MICHAEL A. GUTHRIE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S MICHIGAN AVE STE 100
CHICAGO IL
60616-2119
US

IV. Provider business mailing address

2300 S MICHIGAN AVE STE 100
CHICAGO IL
60616-2119
US

V. Phone/Fax

Practice location:
  • Phone: 872-302-5322
  • Fax: 872-282-0337
Mailing address:
  • Phone: 872-302-5322
  • Fax: 872-282-0337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number019-024222
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: