Provider Demographics
NPI:1184827883
Name:THORSTAD, MICHAEL GARDNER (DDS ORTHODONTIST)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GARDNER
Last Name:THORSTAD
Suffix:
Gender:M
Credentials:DDS ORTHODONTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12765 W FOREST HILL BLVD
Mailing Address - Street 2:WELLINGTON PLAZA SUITE 130
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:561-798-1758
Mailing Address - Fax:561-798-1758
Practice Address - Street 1:12765 W FOREST HILL BLVD
Practice Address - Street 2:WELLINGTON PLAZA SUITE 130
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-798-1758
Practice Address - Fax:561-798-1758
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL77601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics