Provider Demographics
NPI:1669481370
Name:MASSIE, MICHAEL TODD (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TODD
Last Name:MASSIE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N BELLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2038
Mailing Address - Country:US
Mailing Address - Phone:618-258-0028
Mailing Address - Fax:618-258-1060
Practice Address - Street 1:321 N BELLWOOD DR
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2038
Practice Address - Country:US
Practice Address - Phone:618-258-0028
Practice Address - Fax:618-258-1060
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice