Provider Demographics
NPI:1669431482
Name:KORT, MICHAEL A (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:KORT
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 1:1751 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6601
Mailing Address - Country:US
Mailing Address - Phone:928-718-8668
Mailing Address - Fax:928-718-2106
Practice Address - Street 1:1751 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-6601
Practice Address - Country:US
Practice Address - Phone:928-718-8668
Practice Address - Fax:928-718-2106
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZD54321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry