Provider Demographics
NPI:1518061209
Name:KANELLIS, MICHAEL JAMES (DDS MS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:KANELLIS
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 S DENTAL SCIENCE BLDG
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1001
Mailing Address - Country:US
Mailing Address - Phone:319-335-7431
Mailing Address - Fax:319-335-7155
Practice Address - Street 1:322 S DENTAL SCIENCE BLDG
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1001
Practice Address - Country:US
Practice Address - Phone:319-384-1139
Practice Address - Fax:319-384-1785
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA065211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1007047Medicaid