Healthcare Provider Details

I. General information

NPI: 1811334311
Provider Name (Legal Business Name): MICHAEL MOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 E BALDWIN AVE
PAULDING OH
45879
US

IV. Provider business mailing address

PO BOX 359
PAULDING OH
45879
US

V. Phone/Fax

Practice location:
  • Phone: 419-399-3394
  • Fax:
Mailing address:
  • Phone: 419-399-3394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30017678
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: