Provider Demographics
NPI:1639486640
Name:DORSEY, MICHELLE M (DMD, MAGD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:DORSEY
Suffix:
Gender:F
Credentials:DMD, MAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E MERRITT ISLAND CSWY STE M
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3670
Mailing Address - Country:US
Mailing Address - Phone:321-454-4440
Mailing Address - Fax:321-454-9140
Practice Address - Street 1:325 E MERRITT ISLAND CSWY STE M
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3670
Practice Address - Country:US
Practice Address - Phone:321-454-4440
Practice Address - Fax:321-454-9140
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001625500OtherMEDICAID WAIVER PROVIDER