Provider Demographics
NPI:1558871244
Name:DEAN, MICHELLE KIM (LAC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:KIM
Last Name:DEAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-9708
Mailing Address - Country:US
Mailing Address - Phone:831-226-4987
Mailing Address - Fax:
Practice Address - Street 1:1011 HIDDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-9708
Practice Address - Country:US
Practice Address - Phone:831-226-4987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17749171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist