Provider Demographics
NPI:1356507370
Name:DONAHUE, MICHAEL WILLIAM (DDS PC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:DONAHUE
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15859 RIDGELAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2777
Mailing Address - Country:US
Mailing Address - Phone:708-535-2828
Mailing Address - Fax:
Practice Address - Street 1:15859 RIDGELAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-2777
Practice Address - Country:US
Practice Address - Phone:708-535-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018203122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist