Provider Demographics
NPI:1861460263
Name:HORAN, MICHAEL A (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:HORAN
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 1:3820 S FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6503
Mailing Address - Country:US
Mailing Address - Phone:417-882-0948
Mailing Address - Fax:417-882-7548
Practice Address - Street 1:3820 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6503
Practice Address - Country:US
Practice Address - Phone:417-882-0948
Practice Address - Fax:417-882-7548
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T71002Medicare UPIN