Provider Demographics
NPI:1609847342
Name:POTTER, MICHAEL L
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:POTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8305 FALLS OF NEUSE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3546
Mailing Address - Country:US
Mailing Address - Phone:919-841-1720
Mailing Address - Fax:
Practice Address - Street 1:8305 FALLS OF NEUSE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3546
Practice Address - Country:US
Practice Address - Phone:919-841-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS64511223S0112X
NC90241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN