Provider Demographics
NPI:1609896851
Name:BINGHAM, MICHAEL GLENN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLENN
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4538 SWAN LN
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-4707
Mailing Address - Country:US
Mailing Address - Phone:208-851-1679
Mailing Address - Fax:
Practice Address - Street 1:4538 SWAN LN
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59106-4707
Practice Address - Country:US
Practice Address - Phone:208-851-1679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3996122300000X
WY13081223P0221X
SDD11771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist