Provider Demographics
NPI:1740457332
Name:MICHAEL G. SUMMERS DDS, MS, PA
Entity type:Organization
Organization Name:MICHAEL G. SUMMERS DDS, MS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:208-232-0464
Mailing Address - Street 1:1133 CALL CREEK
Mailing Address - Street 2:SUITE B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202
Mailing Address - Country:US
Mailing Address - Phone:208-232-0464
Mailing Address - Fax:208-232-0863
Practice Address - Street 1:1133 CALL CREEK
Practice Address - Street 2:SUITE B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:208-232-0464
Practice Address - Fax:208-232-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3284-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID963311OtherINSURANCE CO.
ID645574OtherUNITED CONCORDIA INS. CO.
ID6G405OtherINSURANCE CO.
ID9202522Medicaid
ID963311OtherUNITED CONCORDIA INSURANCE CO.
ID000015300Medicaid
ID805033500Medicaid
ID9201874Medicaid
ID6G421OtherINSURANCE CO.