Healthcare Provider Details

I. General information

NPI: 1396230090
Provider Name (Legal Business Name): MICHAEL ELI VRACAR II DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GOODMAN RD E
SOUTHAVEN MS
38671-9530
US

IV. Provider business mailing address

730 GOODMAN RD E
SOUTHAVEN MS
38671-9530
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-2351
  • Fax:
Mailing address:
  • Phone: 662-349-2351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number400418
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: