Provider Demographics
NPI:1275552804
Name:BANE, MICHAEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:BANE
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 1:2179 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-1210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2179 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-1210
Practice Address - Country:US
Practice Address - Phone:617-864-8629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA173041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice