Provider Demographics
NPI:1235451212
Name:COLE, MICHAEL DEAN
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEAN
Last Name:COLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7612 TIERRA LAWN CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-2318
Mailing Address - Country:US
Mailing Address - Phone:916-271-0806
Mailing Address - Fax:916-383-1726
Practice Address - Street 1:7612 TIERRA LAWN CT
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-2318
Practice Address - Country:US
Practice Address - Phone:916-271-0806
Practice Address - Fax:916-383-1726
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0025623172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver