Provider Demographics
NPI:1477603389
Name:MAXWELL, MICHAEL G (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:MAXWELL
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 1:9457 SATINLEAF PL
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3962
Mailing Address - Country:US
Mailing Address - Phone:954-895-0536
Mailing Address - Fax:
Practice Address - Street 1:13091 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-0904
Practice Address - Country:US
Practice Address - Phone:954-845-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL137761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice