Healthcare Provider Details

I. General information

NPI: 1356668248
Provider Name (Legal Business Name): MICHAEL THOMAS PINK DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2010
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 MACOM DR
NAPERVILLE IL
60564-3202
US

IV. Provider business mailing address

1303 MACOM DR
NAPERVILLE IL
60564-3202
US

V. Phone/Fax

Practice location:
  • Phone: 630-851-9100
  • Fax: 630-851-6983
Mailing address:
  • Phone: 630-851-9100
  • Fax: 630-851-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS037820
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019026465
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: