Provider Demographics
NPI:1427315431
Name:BACKER, MICHAEL J (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:BACKER
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 1:17300 OUTER 40 RD N.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005
Mailing Address - Country:US
Mailing Address - Phone:636-536-5158
Mailing Address - Fax:636-536-4544
Practice Address - Street 1:17300 OUTER 40 RD N.
Practice Address - Street 2:SUITE 103
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005
Practice Address - Country:US
Practice Address - Phone:636-536-5158
Practice Address - Fax:636-536-4544
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-15
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160062501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery