Provider Demographics
NPI:1063501567
Name:TIERNEY, MICHAEL T (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:TIERNEY
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 1:4781 STATE ROUTE 71
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543
Mailing Address - Country:US
Mailing Address - Phone:630-554-5157
Mailing Address - Fax:630-554-5487
Practice Address - Street 1:4781 STATE ROUTE71
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543
Practice Address - Country:US
Practice Address - Phone:630-554-5157
Practice Address - Fax:630-554-5487
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01914998122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist