Provider Demographics
NPI:1679197156
Name:MACPHAIL, DOMINIQUE RAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:RAE
Last Name:MACPHAIL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9038
Mailing Address - Country:US
Mailing Address - Phone:989-227-1858
Mailing Address - Fax:
Practice Address - Street 1:2192 COMMONS PKWY
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3986
Practice Address - Country:US
Practice Address - Phone:517-349-9257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901600570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program