Provider Demographics
NPI:1306927298
Name:GORMAN, MICHAEL PATRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W GARFIELD
Mailing Address - Street 2:PO BOX 55
Mailing Address - City:CISSNA PARK
Mailing Address - State:FL
Mailing Address - Zip Code:60924
Mailing Address - Country:US
Mailing Address - Phone:815-457-2158
Mailing Address - Fax:815-457-2158
Practice Address - Street 1:121 W GARFIELD
Practice Address - Street 2:
Practice Address - City:CISSNA PARK
Practice Address - State:FL
Practice Address - Zip Code:60924
Practice Address - Country:US
Practice Address - Phone:815-457-2158
Practice Address - Fax:815-457-2158
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist