Provider Demographics
NPI:1326455684
Name:NEISH, MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:NEISH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1126
Mailing Address - Country:US
Mailing Address - Phone:307-871-2023
Mailing Address - Fax:
Practice Address - Street 1:1683 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2812
Practice Address - Country:US
Practice Address - Phone:541-673-3552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009012122300000X
ORD10441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist