Provider Demographics
NPI:1033405691
Name:PROST, MICHAEL ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:PROST
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 1:8272 W LAKE PLEASANT PKWY STE 204
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-7432
Mailing Address - Country:US
Mailing Address - Phone:623-825-7833
Mailing Address - Fax:
Practice Address - Street 1:8272 W LAKE PLEASANT PKWY STE 204
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-7432
Practice Address - Country:US
Practice Address - Phone:623-825-7833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice