Provider Demographics
NPI:1083799266
Name:CALLAHAN, MICHAEL RAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAY
Last Name:CALLAHAN
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:PO BOX 736
Mailing Address - Street 2:12991 JONES STREET
Mailing Address - City:LAVONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30553-0736
Mailing Address - Country:US
Mailing Address - Phone:706-356-1477
Mailing Address - Fax:
Practice Address - Street 1:12991 JONES ST
Practice Address - Street 2:
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-1158
Practice Address - Country:US
Practice Address - Phone:706-356-1477
Practice Address - Fax:706-356-7070
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA108361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice