Provider Demographics
NPI:1962474304
Name:FOSTER, MICHAEL DAVID (DMD, MPH)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:FOSTER
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W SEVIER AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3799
Mailing Address - Country:US
Mailing Address - Phone:423-224-3200
Mailing Address - Fax:
Practice Address - Street 1:117 W SEVIER AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3799
Practice Address - Country:US
Practice Address - Phone:423-224-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA560363AS0400X
KY90271223P0106X, 1223S0112X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000184655OtherBCBS PIN #
KY9500101200Medicaid
KY970014810OtherRR MCARE
KY9500101200Medicaid
KY0326804Medicare ID - Type Unspecified