Provider Demographics
NPI:1063504819
Name:GUTHRIE, MICHAEL A (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GUTHRIE
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 1:1556 S MICHIGAN AVE
Mailing Address - Street 2:110
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2813
Mailing Address - Country:US
Mailing Address - Phone:312-692-0200
Mailing Address - Fax:
Practice Address - Street 1:1556 S MICHIGAN AVE
Practice Address - Street 2:110
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2813
Practice Address - Country:US
Practice Address - Phone:312-692-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0242221223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU67339Medicare UPIN