=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144576240
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. MICHAEL COURTNEY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2012
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 BARTLETT ST STE 405
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01852-1318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-458-1264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1218 WALNUT ST APT 502
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-5441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-755-7203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS039158
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0106X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
-----------------------------------------------------
License Number | DS039158
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------