Provider Demographics
NPI:1326783382
Name:REGAN, MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:REGAN
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 1:169 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-3603
Mailing Address - Country:US
Mailing Address - Phone:570-491-0126
Mailing Address - Fax:
Practice Address - Street 1:169 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3603
Practice Address - Country:US
Practice Address - Phone:507-491-0126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002052191223G0001X
390200000X
PADS044530122300000X
SDD1388122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program