Provider Demographics
NPI:1760005474
Name:PAIGE, MICHELLE SHANTA (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SHANTA
Last Name:PAIGE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 GRAVOIS BLUFFS BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-7720
Mailing Address - Country:US
Mailing Address - Phone:636-203-4100
Mailing Address - Fax:636-203-4105
Practice Address - Street 1:750 GRAVOIS BLUFFS BLVD STE C
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7720
Practice Address - Country:US
Practice Address - Phone:636-203-4100
Practice Address - Fax:636-203-4105
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200138991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice