Healthcare Provider Details

I. General information

NPI: 1417031436
Provider Name (Legal Business Name): MICHAEL LEE BOBO DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 POPLAR STREET
MURRAY KY
42071
US

IV. Provider business mailing address

1109 POPLAR STREET
MURRAY KY
42071
US

V. Phone/Fax

Practice location:
  • Phone: 270-759-4063
  • Fax: 270-759-4920
Mailing address:
  • Phone: 270-759-4063
  • Fax: 270-759-4920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7465 DENTAL
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number34759
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number34759
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: