Provider Demographics
NPI:1245456748
Name:MCCRACKEN, MICHAEL JOHN (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:MCCRACKEN
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 1:1302 RUE BEAUVAIS
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-1235
Mailing Address - Country:US
Mailing Address - Phone:985-624-8559
Mailing Address - Fax:
Practice Address - Street 1:1200 W CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3066
Practice Address - Country:US
Practice Address - Phone:985-674-4441
Practice Address - Fax:985-674-4442
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist