Basic Information
Provider Information | |||||||||
NPI: | 1023166675 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MORGAN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | MAYNES | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 38036 TIMBERLANE DR | ||||||||
Address2: |   | ||||||||
City: | UMATILLA | ||||||||
State: | FL | ||||||||
PostalCode: | 327849399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3526698655 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2140 LAKE EUSTIS DR | ||||||||
Address2: |   | ||||||||
City: | TAVARES | ||||||||
State: | FL | ||||||||
PostalCode: | 327782064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527423500 | ||||||||
FaxNumber: | 3527420668 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2007 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D11130 | FL | Y |   | Dental Providers | Dentist |   |
No ID Information.