Provider Demographics
NPI:1891727582
Name:BAILEY, MICHAEL R (MD, DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BAILEY
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 SOUTH 11TH STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6906
Mailing Address - Country:US
Mailing Address - Phone:208-344-9115
Mailing Address - Fax:208-344-9113
Practice Address - Street 1:403 SOUTH 11TH STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6906
Practice Address - Country:US
Practice Address - Phone:208-344-9115
Practice Address - Fax:208-344-9113
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF38380Medicare UPIN
1375019Medicare PIN