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General NPI Number Information
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NPI Number | 1407558851
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Entity Type | Individual
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Provider Name | MICHELLE MA DDS
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Gender | Female
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Dates
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Enumeration Date | 03/20/2023
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 193 BROADWAY STE 2
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City | AMITYVILLE
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State | NY
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Zip | 11701-2761
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Country | US
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Telephone | 631-598-2940
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Fax |
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Provider Business Mailing Address
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Address Line | 193 BROADWAY STE 2
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City | AMITYVILLE
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State | NY
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Zip | 11701-2761
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Country | US
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Telephone | 631-598-2940
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 064340
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License Number State | NY
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