Provider Demographics
NPI:1710023874
Name:DUCKWORTH, E. MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:E.
Middle Name:MICHAEL
Last Name:DUCKWORTH
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 1:1506 GLENLAKE CIR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3825
Mailing Address - Country:US
Mailing Address - Phone:850-897-9600
Mailing Address - Fax:
Practice Address - Street 1:4566 E HIGHWAY 20 STE 108
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8839
Practice Address - Country:US
Practice Address - Phone:850-897-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN155511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice