Provider Demographics
NPI:1245783430
Name:MCCUNNIFF, MICHAEL LEE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:MCCUNNIFF
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 1:142 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4716
Mailing Address - Country:US
Mailing Address - Phone:888-468-0022
Mailing Address - Fax:
Practice Address - Street 1:1350 SE UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-8933
Practice Address - Country:US
Practice Address - Phone:319-939-4105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD105041223G0001X
IADDS-094901223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice