Provider Demographics
NPI:1124279856
Name:PROOTHI, MICHAEL (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PROOTHI
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 HALLOCK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3072
Mailing Address - Country:US
Mailing Address - Phone:631-675-9601
Mailing Address - Fax:631-675-9602
Practice Address - Street 1:207 HALLOCK RD STE 2
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3072
Practice Address - Country:US
Practice Address - Phone:631-675-9601
Practice Address - Fax:631-675-9602
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051735204E00000X
NY260012204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery