Provider Demographics
NPI:1093164097
Name:LE, MICHAEL T (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:LE
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 1:4048 BERKMAN DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-4543
Mailing Address - Country:US
Mailing Address - Phone:951-231-7246
Mailing Address - Fax:
Practice Address - Street 1:16560 R R 620 STE 104
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5803
Practice Address - Country:US
Practice Address - Phone:512-432-5450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6847122300000X
TX32636122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist