Provider Demographics
NPI:1932466851
Name:MCHALE, MICHELLE G
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:G
Last Name:MCHALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 W 83RD ST
Mailing Address - Street 2:#268
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-5308
Mailing Address - Country:US
Mailing Address - Phone:612-396-8842
Mailing Address - Fax:
Practice Address - Street 1:4601 W 109TH ST
Practice Address - Street 2:SUITE #212
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1318
Practice Address - Country:US
Practice Address - Phone:913-954-4174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO20160152611223P0300X
MND13101122300000X
KS61145122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223P0300XDental ProvidersDentistPeriodontics