Provider Demographics
NPI:1669204665
Name:VILLA, MICHAEL DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:VILLA
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 1:15406 JEWEL AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15406 JEWEL AVE APT 3C
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1846
Practice Address - Country:US
Practice Address - Phone:347-552-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-17
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0641341223P0300X
NY027079124Q00000X
NJ22DI030156001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No124Q00000XDental ProvidersDental Hygienist