Provider Demographics
NPI:1407141807
Name:SPARKS, MICHAEL C (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:SPARKS
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 1:1836 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-2708
Mailing Address - Country:US
Mailing Address - Phone:270-442-0256
Mailing Address - Fax:270-442-8730
Practice Address - Street 1:1836 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-2708
Practice Address - Country:US
Practice Address - Phone:270-442-0256
Practice Address - Fax:270-442-8730
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9016122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist