Provider Demographics
NPI:1023057163
Name:MYERS, MICHELL B (DMD, PC)
Entity type:Individual
Prefix:DR
First Name:MICHELL
Middle Name:B
Last Name:MYERS
Suffix:
Gender:M
Credentials:DMD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 STARFIRE DR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1624
Mailing Address - Country:US
Mailing Address - Phone:815-433-3413
Mailing Address - Fax:815-433-3476
Practice Address - Street 1:1300 STARFIRE DR
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1624
Practice Address - Country:US
Practice Address - Phone:815-433-3413
Practice Address - Fax:815-433-3476
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice