Provider Demographics
NPI:1265486161
Name:BRACE, MICHAEL LEROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEROY
Last Name:BRACE
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 1:3511 CANYON DE FLORES
Mailing Address - Street 2:SUITE B
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-5378
Mailing Address - Country:US
Mailing Address - Phone:520-378-6684
Mailing Address - Fax:
Practice Address - Street 1:3511 CANYON DE FLORES
Practice Address - Street 2:SUITE B
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650-5378
Practice Address - Country:US
Practice Address - Phone:520-378-6684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63171223G0001X
MO0143371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice