Provider Demographics
NPI:1194849091
Name:KOVALL, MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:KOVALL
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 1:1030 SAINT GEORGES AVE
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1390
Practice Address - Country:US
Practice Address - Phone:732-750-0707
Practice Address - Fax:732-750-4240
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ109671223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery