Provider Demographics
NPI:1780096321
Name:MCTAGUE, MICHELE M (RDH, BS)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:M
Last Name:MCTAGUE
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-129 APUU PL
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3915
Mailing Address - Country:US
Mailing Address - Phone:808-477-2600
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVENUE
Practice Address - Street 2:NAVAL HEALTH CLINIC HAWAII
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-477-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDH1384124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist