Provider Demographics
NPI:1255645404
Name:MICHAEL, MARY M (DDS)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4508
Mailing Address - Country:US
Mailing Address - Phone:607-778-1400
Mailing Address - Fax:
Practice Address - Street 1:37 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4508
Practice Address - Country:US
Practice Address - Phone:607-778-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY500550631223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice