Provider Demographics
NPI:1598801037
Name:PICHARDO, MICHAEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:PICHARDO
Suffix:
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 1:7915 LAKE MANASSAS DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3258
Mailing Address - Country:US
Mailing Address - Phone:703-753-4901
Mailing Address - Fax:
Practice Address - Street 1:7915 LAKE MANASSAS DR STE 203
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3259
Practice Address - Country:US
Practice Address - Phone:703-753-4901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191911223E0200X
VA04014117461223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics