Provider Demographics
NPI:1154062990
Name:CEVALLOS, MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CEVALLOS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11919 RIMSWELL MEWS
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112
Mailing Address - Country:US
Mailing Address - Phone:804-433-5921
Mailing Address - Fax:
Practice Address - Street 1:100 GALLATIN STREET NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-2027
Practice Address - Country:US
Practice Address - Phone:202-483-8196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN20002891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty