Healthcare Provider Details

I. General information

NPI: 1518097294
Provider Name (Legal Business Name): MICHAEL WOOD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 SOUTH MAIN STREET
LONDON KY
40741
US

IV. Provider business mailing address

828 SOUTH MAIN STREET
LONDON KY
40741
US

V. Phone/Fax

Practice location:
  • Phone: 606-878-7251
  • Fax: 606-878-1285
Mailing address:
  • Phone: 606-878-7251
  • Fax: 606-878-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6869
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6869
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: