Provider Demographics
NPI:1346502465
Name:PRATHER, MICHELLE (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PRATHER
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 1:316 MDG/MALCOLM GROW MEDICAL CLINICS & SURGERY CENTER
Mailing Address - Street 2:1060 W. PERIMETER ROAD, SUITE 3K43
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6600
Mailing Address - Country:US
Mailing Address - Phone:618-960-9065
Mailing Address - Fax:
Practice Address - Street 1:316 MDG/MALCOLM GROW MEDICAL CLINICS & SURGERY CENTER
Practice Address - Street 2:1060 W. PERIMETER ROAD, SUITE 3K43
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6600
Practice Address - Country:US
Practice Address - Phone:618-960-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028636122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-028636OtherIL LICENSE