Provider Demographics
NPI:1285003954
Name:METCALF, MICHELLE (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:METCALF
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S 8TH AVE
Mailing Address - Street 2:CAMPUS BOX 8088
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-8088
Mailing Address - Country:US
Mailing Address - Phone:208-282-6000
Mailing Address - Fax:
Practice Address - Street 1:921 S 8TH AVE
Practice Address - Street 2:CAMPUS BOX 8088
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-8088
Practice Address - Country:US
Practice Address - Phone:208-282-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist