Provider Demographics
NPI:1669552758
Name:MICHAEL W FUQUA DDS
Entity type:Organization
Organization Name:MICHAEL W FUQUA DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-425-7474
Mailing Address - Street 1:2202 S 77 SUNSHINE STRIP
Mailing Address - Street 2:STE B
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550
Mailing Address - Country:US
Mailing Address - Phone:956-425-7474
Mailing Address - Fax:956-425-3555
Practice Address - Street 1:2202 S 77 SUNSHINE STRIP
Practice Address - Street 2:STE B
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550
Practice Address - Country:US
Practice Address - Phone:956-425-7474
Practice Address - Fax:956-425-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120848003Medicaid
TX1626501OtherTEXAS CHYOS