Basic Information
| Provider Information | |||||||||
| NPI: | 1952362931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADU-TUTU | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5150 NW MILNER DR | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349833392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724623874 | ||||||||
| FaxNumber: | 7724623874 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 AVENUE C | ||||||||
| Address2: | |||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349504189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724623874 | ||||||||
| FaxNumber: | 7724623880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 01/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D2934 | AZ | N | Dental Providers | Dentist | 122300000X | DN10216 | FL | Y | Dental Providers | Dentist | 122300000X | 56698 | CA | N | Dental Providers | Dentist | 122300000X | DS0000004304 | TN | N | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 83600 | 05 | AZ | MEDICAID |