Provider Demographics
NPI:1114166535
Name:JESTER, MICHAEL ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:JESTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PUBLIC SQ
Mailing Address - Street 2:SUITE C
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-1393
Mailing Address - Country:US
Mailing Address - Phone:317-392-3148
Mailing Address - Fax:
Practice Address - Street 1:16 PUBLIC SQ
Practice Address - Street 2:SUITE C
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1393
Practice Address - Country:US
Practice Address - Phone:317-392-3148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008644A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice