Provider Demographics
NPI:1356630511
Name:AMMONS, MICHAEL WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:AMMONS
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 1:1 FREEDOM WAY
Mailing Address - Street 2:DENTAL CLINIC, 233U
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6258
Mailing Address - Country:US
Mailing Address - Phone:843-276-0564
Mailing Address - Fax:706-481-6721
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:DENTAL CLINIC, 233U
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:843-276-0564
Practice Address - Fax:706-481-6721
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist