Provider Demographics
NPI:1225219355
Name:PATRICIAN, MICHAEL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:PATRICIAN
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 1:109 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1523
Mailing Address - Country:US
Mailing Address - Phone:570-586-8986
Mailing Address - Fax:
Practice Address - Street 1:109 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1522
Practice Address - Country:US
Practice Address - Phone:570-586-8986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023284122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist