Provider Demographics
NPI:1770678674
Name:NEAL, MICHELLE FOGG (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:FOGG
Last Name:NEAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9750 NE 120TH PL STE 5
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4207
Mailing Address - Country:US
Mailing Address - Phone:425-823-1234
Mailing Address - Fax:
Practice Address - Street 1:9750 NE 120TH PL STE 5
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4207
Practice Address - Country:US
Practice Address - Phone:425-823-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000085511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics