Provider Demographics
NPI:1811129919
Name:MAAK, MICHELLE KRISTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:KRISTIN
Last Name:MAAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:KRISTIN
Other - Last Name:MAAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:6268 S 900 E
Mailing Address - Street 2:STE 100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2497
Mailing Address - Country:US
Mailing Address - Phone:801-566-5117
Mailing Address - Fax:
Practice Address - Street 1:6268 S 900 E
Practice Address - Street 2:STE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-2497
Practice Address - Country:US
Practice Address - Phone:801-566-5117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0545971223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7372659-9924OtherLICENSE