Provider Demographics
NPI:1760562318
Name:WITSIL, MICHAEL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:WITSIL
Suffix:
Gender:M
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:P.O. BOX 69 7300 KLAWOCK-HOLLIS HWY,
Mailing Address - Street 2:ALICIA ROBERTS MEDICAL CENTER
Mailing Address - City:KLAWOCK
Mailing Address - State:AK
Mailing Address - Zip Code:99925
Mailing Address - Country:US
Mailing Address - Phone:907-755-4918
Mailing Address - Fax:
Practice Address - Street 1:7300 KLAWOCK-HOLLIS HWY.
Practice Address - Street 2:ALICIA ROBERTS MEDICAL CENTER
Practice Address - City:KLAWOCK
Practice Address - State:AK
Practice Address - Zip Code:99925
Practice Address - Country:US
Practice Address - Phone:907-755-4918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN168831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice