Provider Demographics
NPI:1831225044
Name:POTTER, MICHAEL IRVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:IRVIN
Last Name:POTTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4101 MORRIS ST NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3605
Mailing Address - Country:US
Mailing Address - Phone:505-275-0700
Mailing Address - Fax:505-237-0596
Practice Address - Street 1:4101 MORRIS ST NE
Practice Address - Street 2:SUITE E
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3605
Practice Address - Country:US
Practice Address - Phone:505-275-0700
Practice Address - Fax:505-237-0596
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM10981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice