Provider Demographics
NPI:1336233030
Name:CARL, MICHAEL JOHN
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:CARL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51071 WETHERBEE RD
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:MI
Mailing Address - Zip Code:49067
Mailing Address - Country:US
Mailing Address - Phone:269-273-8467
Mailing Address - Fax:
Practice Address - Street 1:435 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MENDON
Practice Address - State:MI
Practice Address - Zip Code:49072
Practice Address - Country:US
Practice Address - Phone:269-496-8484
Practice Address - Fax:269-496-8485
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI135931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice