Healthcare Provider Details

I. General information

NPI: 1639131840
Provider Name (Legal Business Name): JERRY D. MICHEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4TH AND WEST VIRGINIA BLDG 500 HARPER DENTAL CLINIC
FT WOOD MO
65473
US

IV. Provider business mailing address

25279 MCCLURG RD
VERSAILLES MO
65084-5769
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0408
  • Fax: 573-596-0314
Mailing address:
  • Phone: 573-372-2786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number011804
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4931
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: