Provider Demographics
NPI:1952314262
Name:MCDANIELS, MICHAEL D (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MCDANIELS
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:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0509
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:203 MCCOMB ST
Practice Address - Street 2:
Practice Address - City:WILMOT
Practice Address - State:AR
Practice Address - Zip Code:71676
Practice Address - Country:US
Practice Address - Phone:870-473-2311
Practice Address - Fax:870-473-5392
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58432OtherBLUE CROSS BLUE SHIELD
AR100948608Medicaid
AR1748OtherSTATE LICENSE
AR100948608Medicaid