Provider Demographics
NPI:1003919036
Name:WINTER, MICHAEL C (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:WINTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PROFESSIONAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082
Mailing Address - Country:US
Mailing Address - Phone:904-285-9173
Mailing Address - Fax:904-285-5346
Practice Address - Street 1:100 PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082
Practice Address - Country:US
Practice Address - Phone:904-285-9173
Practice Address - Fax:904-285-5346
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN102011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
656344OtherTRICARE
656344OtherUC
FL67183Medicare ID - Type Unspecified