Provider Demographics
NPI:1306826508
Name:MUTO, J MICHAEL II (DDS)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:MICHAEL
Last Name:MUTO
Suffix:II
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 1:3860 TEAYS VALLEY RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9772
Mailing Address - Country:US
Mailing Address - Phone:304-757-1000
Mailing Address - Fax:304-757-1091
Practice Address - Street 1:3860 TEAYS VALLEY RD
Practice Address - Street 2:SUITE 5
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9772
Practice Address - Country:US
Practice Address - Phone:304-757-1000
Practice Address - Fax:304-757-1091
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3511122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4003058000Medicaid