Provider Demographics
NPI:1235352055
Name:DOLBY, MICHAEL G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:DOLBY
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 1:90 COTTONWOOD CT STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6577
Mailing Address - Country:US
Mailing Address - Phone:208-323-8545
Mailing Address - Fax:208-938-1401
Practice Address - Street 1:90 COTTONWOOD CT STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6577
Practice Address - Country:US
Practice Address - Phone:208-323-8545
Practice Address - Fax:208-938-1401
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD-3114OtherSTATE LICENSE
IDBD4077702OtherDEA