Provider Demographics
NPI:1043249436
Name:MIN, MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-2603
Mailing Address - Country:US
Mailing Address - Phone:909-989-1556
Mailing Address - Fax:909-989-3132
Practice Address - Street 1:1921 E 4TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-2603
Practice Address - Country:US
Practice Address - Phone:909-989-1556
Practice Address - Fax:909-989-3132
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA501631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice