Provider Demographics
NPI:1912133935
Name:DICK, MICHAEL ROBERT (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:DICK
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 1:3901 DUTCHMANS LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4722
Mailing Address - Country:US
Mailing Address - Phone:502-895-2218
Mailing Address - Fax:502-895-2268
Practice Address - Street 1:3901 DUTCHMANS LN
Practice Address - Street 2:SUITE 201
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4722
Practice Address - Country:US
Practice Address - Phone:502-895-2218
Practice Address - Fax:502-895-2268
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice