Provider Demographics
NPI:1205181179
Name:IGNACIO, MICHAEL E (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:IGNACIO
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 1:1009 E. MOUNTAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207
Mailing Address - Country:US
Mailing Address - Phone:818-636-4057
Mailing Address - Fax:
Practice Address - Street 1:1916 W. COLORADO
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041
Practice Address - Country:US
Practice Address - Phone:323-340-8014
Practice Address - Fax:323-340-8932
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA614501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice