Healthcare Provider Details

I. General information

NPI: 1245928654
Provider Name (Legal Business Name): MICHAEL BACKSTRAND DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2848 CHURCH AVE
BROOKLYN NY
11226-8270
US

IV. Provider business mailing address

429 PALERMO CIR
FORT MYERS BEACH FL
33931-2726
US

V. Phone/Fax

Practice location:
  • Phone: 718-282-8222
  • Fax:
Mailing address:
  • Phone: 239-994-5026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number065470
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: