Provider Demographics
NPI:1972985364
Name:PARKER, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PARKER
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 1:506 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-1829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13961 60TH ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-1053
Practice Address - Country:US
Practice Address - Phone:715-235-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001108-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist