Provider Demographics
NPI:1235620931
Name:MCDOUGAL, MICHAEL D (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MCDOUGAL
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 1:3228 E FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5527
Mailing Address - Country:US
Mailing Address - Phone:480-861-7265
Mailing Address - Fax:
Practice Address - Street 1:1901 S SIGNAL BUTTE RD STE 107
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2601
Practice Address - Country:US
Practice Address - Phone:480-305-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist