Provider Demographics
NPI:1073779633
Name:PEREZ, MICHELLE N (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:N
Last Name:PEREZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64124-2323
Mailing Address - Country:US
Mailing Address - Phone:816-474-4920
Mailing Address - Fax:816-474-4914
Practice Address - Street 1:825 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64124-2323
Practice Address - Country:US
Practice Address - Phone:816-474-4920
Practice Address - Fax:816-474-4914
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS605891223G0001X
MO20110017771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC16000067OtherPTAN
KS200579650AMedicaid
MO1073779633Medicaid
KS002063585OtherUNITED CONCORIDA