Provider Demographics
NPI:1245673441
Name:DEGOULD, MICHAEL DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:DEGOULD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:2835 MCFARLAND RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6819
Mailing Address - Country:US
Mailing Address - Phone:815-654-0039
Mailing Address - Fax:815-654-0650
Practice Address - Street 1:2835 MCFARLAND RD
Practice Address - Street 2:SUITE C
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6819
Practice Address - Country:US
Practice Address - Phone:815-654-0039
Practice Address - Fax:815-654-0650
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0190197221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery