Provider Demographics
NPI:1225036189
Name:DUVAL, MICHAEL C (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:DUVAL
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 1:2640 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:REEDSPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97467-1813
Mailing Address - Country:US
Mailing Address - Phone:541-271-4858
Mailing Address - Fax:541-271-4859
Practice Address - Street 1:2640 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467-1813
Practice Address - Country:US
Practice Address - Phone:541-271-4858
Practice Address - Fax:541-271-4859
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-14
Provider Licenses
StateLicense IDTaxonomies
ORD055411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR078758Medicaid