Provider Demographics
NPI:1932228236
Name:CONDON, MICHAEL P (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:CONDON
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 1:2207 N MOLTER RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7570
Mailing Address - Country:US
Mailing Address - Phone:509-926-5272
Mailing Address - Fax:509-926-4855
Practice Address - Street 1:2207 N MOLTER RD
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7570
Practice Address - Country:US
Practice Address - Phone:509-926-5272
Practice Address - Fax:509-926-4855
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA84401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5031976Medicaid