Provider Demographics
NPI:1649726886
Name:DOTSON, MICHELLE R
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:R
Last Name:DOTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12115 W VAN BUREN ST APT 1924
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7251
Mailing Address - Country:US
Mailing Address - Phone:623-383-3031
Mailing Address - Fax:623-399-1052
Practice Address - Street 1:12115 W VAN BUREN ST APT 1924
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:623-383-3031
Practice Address - Fax:623-399-1052
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ171WOOOOOX171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor