Provider Demographics
NPI:1093454746
Name:QUIZ, MICHAEL TIMOTHY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:QUIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4465 S COUNTY ROAD 125 E
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-9237
Mailing Address - Country:US
Mailing Address - Phone:765-719-1479
Mailing Address - Fax:
Practice Address - Street 1:10967 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7980
Practice Address - Country:US
Practice Address - Phone:317-272-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013873A122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program