Provider Demographics
NPI:1649097627
Name:MYERS, MICHAEL A
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:MYERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15171 MONTFORT DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-7432
Mailing Address - Country:US
Mailing Address - Phone:317-289-1750
Mailing Address - Fax:
Practice Address - Street 1:3837 N HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2742
Practice Address - Country:US
Practice Address - Phone:317-522-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014460A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics