Provider Demographics
NPI:1215022496
Name:BOND, MICHAEL LEE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:BOND
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:PO BOX 558
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:VA
Mailing Address - Zip Code:24557
Mailing Address - Country:US
Mailing Address - Phone:434-656-3573
Mailing Address - Fax:434-656-3573
Practice Address - Street 1:603 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:VA
Practice Address - Zip Code:24557
Practice Address - Country:US
Practice Address - Phone:434-656-3573
Practice Address - Fax:434-565-3573
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005648122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA78-1741-0Medicaid