Healthcare Provider Details

I. General information

NPI: 1144576240
Provider Name (Legal Business Name): DR. MICHAEL COURTNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 BARTLETT ST STE 405
LOWELL MA
01852-1318
US

IV. Provider business mailing address

1218 WALNUT ST APT 502
PHILADELPHIA PA
19107-5441
US

V. Phone/Fax

Practice location:
  • Phone: 978-458-1264
  • Fax:
Mailing address:
  • Phone: 617-755-7203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS039158
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDS039158
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: