Provider Demographics
NPI:1710961495
Name:MARCHETTI, MICHAEL ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:MARCHETTI
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 1:1511 BROADWAY
Mailing Address - Street 2:BOX 84
Mailing Address - City:WHEATON
Mailing Address - State:MN
Mailing Address - Zip Code:56296-1040
Mailing Address - Country:US
Mailing Address - Phone:320-563-4800
Mailing Address - Fax:
Practice Address - Street 1:1511 BROADWAY
Practice Address - Street 2:BOX 84
Practice Address - City:WHEATON
Practice Address - State:MN
Practice Address - Zip Code:56296-1040
Practice Address - Country:US
Practice Address - Phone:320-563-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9547Medicaid