Healthcare Provider Details

I. General information

NPI: 1770985475
Provider Name (Legal Business Name): MICHAEL D LOEW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22D MEDICAL GROUP 57950 LEAVENWORTH ST
MCCONNELL AFB KS
67221-3506
US

IV. Provider business mailing address

22D MEDICAL GROUP 57950 LEAVENWORTH ST
MCCONNELL AFB KS
67221-3506
US

V. Phone/Fax

Practice location:
  • Phone: 316-759-5181
  • Fax: 316-759-6277
Mailing address:
  • Phone: 316-759-5181
  • Fax: 316-759-6277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number09144
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: