Provider Demographics
NPI:1477623270
Name:MCENTIRE, MICHAEL VERNON II (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VERNON
Last Name:MCENTIRE
Suffix:II
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 1:418 N BRIARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4103
Mailing Address - Country:US
Mailing Address - Phone:928-472-7554
Mailing Address - Fax:
Practice Address - Street 1:300 W AIRPORT RD
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-3607
Practice Address - Country:US
Practice Address - Phone:928-474-3216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD56741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice