Provider Demographics
NPI:1417031436
Name:BOBO, MICHAEL LEE (DDS MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:BOBO
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 POPLAR STREET
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071
Mailing Address - Country:US
Mailing Address - Phone:270-759-4063
Mailing Address - Fax:270-759-4920
Practice Address - Street 1:1109 POPLAR STREET
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071
Practice Address - Country:US
Practice Address - Phone:270-759-4063
Practice Address - Fax:270-759-4920
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7465 DENTAL1223S0112X
KY347591223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000163Medicaid
KY64011711Medicaid
KY1836201Medicare PIN
KY64011711Medicaid