Provider Demographics
NPI:1114007838
Name:MICHEAL J DEADY DDS INC
Entity Type:Organization
Organization Name:MICHEAL J DEADY DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DEADY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-232-2108
Mailing Address - Street 1:1630 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807
Mailing Address - Country:US
Mailing Address - Phone:812-232-2108
Mailing Address - Fax:812-232-2426
Practice Address - Street 1:1630 POPLAR ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807
Practice Address - Country:US
Practice Address - Phone:812-232-2108
Practice Address - Fax:812-232-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006188204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U22450Medicare UPIN
INDE853190Medicare ID - Type Unspecified