Provider Demographics
NPI:1932263035
Name:CHILDERS, MICHAEL (DMD, M S)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:DMD, M S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 PHILLIPS LN
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40209-1312
Mailing Address - Country:US
Mailing Address - Phone:502-375-0095
Mailing Address - Fax:
Practice Address - Street 1:644 PHILLIPS LN
Practice Address - Street 2:SUITE 1002
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40209-1312
Practice Address - Country:US
Practice Address - Phone:502-375-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY67251223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics