Provider Demographics
NPI:1043352412
Name:CARMICHAEL, LONNY D (DDS)
Entity Type:Individual
Prefix:
First Name:LONNY
Middle Name:D
Last Name:CARMICHAEL
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 1:3592 S ATHERTON BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7443
Mailing Address - Country:US
Mailing Address - Phone:480-889-1877
Mailing Address - Fax:480-889-1876
Practice Address - Street 1:3592 S ATHERTON BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7443
Practice Address - Country:US
Practice Address - Phone:480-889-1877
Practice Address - Fax:480-889-1876
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411545122300000X
AZ74601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ348451Medicaid