Healthcare Provider Details

I. General information

NPI: 1669481370
Provider Name (Legal Business Name): MICHAEL TODD MASSIE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N BELLWOOD DR
EAST ALTON IL
62024-2038
US

IV. Provider business mailing address

321 N BELLWOOD DR
EAST ALTON IL
62024-2038
US

V. Phone/Fax

Practice location:
  • Phone: 618-258-0028
  • Fax: 618-258-1060
Mailing address:
  • Phone: 618-258-0028
  • Fax: 618-258-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: