Provider Demographics
NPI:1336152966
Name:STURT, MICHAEL DEREK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DEREK
Last Name:STURT
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 1:8 WASHITAY AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-1925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5400 W ELM ST
Practice Address - Street 2:STE 212
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4010
Practice Address - Country:US
Practice Address - Phone:815-578-1000
Practice Address - Fax:815-578-1229
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice