Provider Demographics
NPI:1518434398
Name:CLINTON MUNOZ, MICHELLE LIEN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LIEN
Last Name:CLINTON MUNOZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 REVEILLE CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-9157
Mailing Address - Country:US
Mailing Address - Phone:214-215-0558
Mailing Address - Fax:
Practice Address - Street 1:1917 REVEILLE CIR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-9157
Practice Address - Country:US
Practice Address - Phone:214-215-0558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160238961223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty