Provider Demographics
NPI:1407067564
Name:WOOD, MICHAEL G (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:WOOD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 INNSDALE TER
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3061
Mailing Address - Country:US
Mailing Address - Phone:505-762-7797
Mailing Address - Fax:505-762-7738
Practice Address - Street 1:211 INNSDALE TER
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3061
Practice Address - Country:US
Practice Address - Phone:505-762-7797
Practice Address - Fax:505-762-7738
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD11721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice