Provider Demographics
NPI:1912172503
Name:HIGGINSON, MICHAEL LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LYNN
Last Name:HIGGINSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5017
Mailing Address - Country:US
Mailing Address - Phone:208-939-3010
Mailing Address - Fax:208-939-3027
Practice Address - Street 1:1177 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5017
Practice Address - Country:US
Practice Address - Phone:208-939-3010
Practice Address - Fax:208-939-3027
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-33801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice