Provider Demographics
NPI:1417518069
Name:BOARD, MICHAEL TROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TROY
Last Name:BOARD
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 1:5357 SNOW OWL DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5076
Mailing Address - Country:US
Mailing Address - Phone:540-588-2645
Mailing Address - Fax:
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-828-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014165691223S0112X, 204E00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery