Provider Demographics
NPI:1700879442
Name:MIDDLEBROOKS, MICHAEL LOUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOUIS
Last Name:MIDDLEBROOKS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4232 BAYMEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4604
Mailing Address - Country:US
Mailing Address - Phone:904-739-0690
Mailing Address - Fax:904-737-1045
Practice Address - Street 1:4232 BAYMEADOWS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4604
Practice Address - Country:US
Practice Address - Phone:904-739-0690
Practice Address - Fax:904-737-1045
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 79341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU32561Medicare UPIN