Healthcare Provider Details

I. General information

NPI: 1265417984
Provider Name (Legal Business Name): MARTHA JOAN MICHAELSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX A FPO AP 96350
YOKOSUKA JAPAN
96350
JP

IV. Provider business mailing address

PSC 475 BOX A FPO AP 96350
YOKOSUKA JAPAN
96350
JP

V. Phone/Fax

Practice location:
  • Phone: 01181468168808
  • Fax: 01181468168791
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7659
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: