Provider Demographics
NPI:1609958479
Name:MICHAELSON, DENNIS J (DMD MS)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:J
Last Name:MICHAELSON
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2271 OVERLAND AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318
Mailing Address - Country:US
Mailing Address - Phone:208-678-3265
Mailing Address - Fax:208-678-5206
Practice Address - Street 1:2271 OVERLAND AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318
Practice Address - Country:US
Practice Address - Phone:208-678-3265
Practice Address - Fax:208-678-5206
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDD1497OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics