Provider Demographics
NPI:1417048182
Name:MCDANIEL, MICHAEL DAVID (DMDPA)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:DMDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 972
Mailing Address - Street 2:501 PARK AVENUE
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-0972
Mailing Address - Country:US
Mailing Address - Phone:662-887-1272
Mailing Address - Fax:662-887-6453
Practice Address - Street 1:501 PARK AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2355
Practice Address - Country:US
Practice Address - Phone:662-887-1272
Practice Address - Fax:662-887-6453
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2738931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660041Medicaid