Provider Demographics
NPI:1619003134
Name:MAIN, MICHAEL RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAY
Last Name:MAIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:RAY
Other - Last Name:MAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:9513 AURORA AVE
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-1459
Mailing Address - Country:US
Mailing Address - Phone:319-325-6500
Mailing Address - Fax:515-223-1069
Practice Address - Street 1:1701 22ND ST STE 101
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1443
Practice Address - Country:US
Practice Address - Phone:515-224-4867
Practice Address - Fax:515-223-1069
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice