Provider Demographics
NPI:1629168802
Name:MCDONALD, MICHAEL T (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:M.
Other - Middle Name:T
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS,PA
Mailing Address - Street 1:112 PECAN ORCHARD LANE
Mailing Address - Street 2:P. O. BOX 421
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-0421
Mailing Address - Country:US
Mailing Address - Phone:662-256-2378
Mailing Address - Fax:
Practice Address - Street 1:400 2ND AVE N
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-3513
Practice Address - Country:US
Practice Address - Phone:662-256-5601
Practice Address - Fax:662-256-5602
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1549-731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice