Provider Demographics
NPI:1508906736
Name:MINNICH, MICHAEL DAVID (DDS,MS, INC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:MINNICH
Suffix:
Gender:M
Credentials:DDS,MS, INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 SEAGAZE DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-3006
Mailing Address - Country:US
Mailing Address - Phone:760-721-1552
Mailing Address - Fax:760-721-6821
Practice Address - Street 1:713 SEAGAZE DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-3006
Practice Address - Country:US
Practice Address - Phone:760-721-1552
Practice Address - Fax:760-721-6821
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA354321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86-1095806OtherTAX ID #