Provider Demographics
NPI:1326504176
Name:PHELAN, MICHELLE KATHRYN
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:KATHRYN
Last Name:PHELAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 SW 14TH AVE APT B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-2826
Mailing Address - Country:US
Mailing Address - Phone:904-742-2278
Mailing Address - Fax:
Practice Address - Street 1:2575 SW 42ND ST UNIT 104
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-1356
Practice Address - Country:US
Practice Address - Phone:352-877-4926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23351122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist