Provider Demographics
NPI:1629525258
Name:MASTERSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MASTERSON
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 1:1815 SE US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-9065
Mailing Address - Country:US
Mailing Address - Phone:352-795-1223
Mailing Address - Fax:352-795-1637
Practice Address - Street 1:1815 SE US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-9065
Practice Address - Country:US
Practice Address - Phone:352-795-1223
Practice Address - Fax:352-795-1637
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist