Provider Demographics
NPI:1598989840
Name:SUMMERS, MICHAEL G (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:SUMMERS
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 1:1133 CALL CREEK DR.
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3000
Mailing Address - Country:US
Mailing Address - Phone:208-232-0464
Mailing Address - Fax:208-232-0863
Practice Address - Street 1:1133 CALL CREEK DR.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3000
Practice Address - Country:US
Practice Address - Phone:208-232-0464
Practice Address - Fax:208-232-0863
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3284-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID963311OtherUCCI
ID6G421OtherBLUE CROSS OF IDAHO
ID6G405OtherBLUE CROSS OF ID