Provider Demographics
NPI:1679664049
Name:MACAITIS, MICHAEL KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:MACAITIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E ERIE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOURI VALLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51555-1533
Mailing Address - Country:US
Mailing Address - Phone:712-642-4136
Mailing Address - Fax:712-642-3664
Practice Address - Street 1:214 E ERIE ST
Practice Address - Street 2:
Practice Address - City:MISSOURI VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51555-1533
Practice Address - Country:US
Practice Address - Phone:712-642-4136
Practice Address - Fax:712-642-3664
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2152637Medicaid