Provider Demographics
NPI:1124154174
Name:MACEY, MICHELLE (DMD)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:MACEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1338 SANTA ROSA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3780
Mailing Address - Country:US
Mailing Address - Phone:805-544-3221
Mailing Address - Fax:805-544-3221
Practice Address - Street 1:1338 SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3780
Practice Address - Country:US
Practice Address - Phone:805-544-3221
Practice Address - Fax:805-544-3221
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA31492OtherLISCENCE NUMBER
CA31492OtherLISCENCE NUMBER