Healthcare Provider Details

I. General information

NPI: 1003107848
Provider Name (Legal Business Name): MR. MICHAEL J.G. COON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3232 W HOUGHTON LAKE DR
HOUGHTON LAKE MI
48629-8244
US

IV. Provider business mailing address

3232 W HOUGHTON LAKE DR
HOUGHTON LAKE MI
48629-8244
US

V. Phone/Fax

Practice location:
  • Phone: 989-366-6971
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: