Provider Demographics
NPI:1821210568
Name:MCNUTT, MICHAEL PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:MCNUTT
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 1:1881 N PONTIAC TRL
Mailing Address - Street 2:SUITE A
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3101
Mailing Address - Country:US
Mailing Address - Phone:248-624-5996
Mailing Address - Fax:248-624-5997
Practice Address - Street 1:1881 N PONTIAC TRL
Practice Address - Street 2:SUITE A
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3101
Practice Address - Country:US
Practice Address - Phone:248-624-5996
Practice Address - Fax:248-624-5997
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI165321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice