Provider Demographics
NPI:1528272887
Name:PRUEHER, MICHAEL JOHN (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:PRUEHER
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:DENTAL SOUTH P A
Mailing Address - Street 2:800 MARIE AVENUE
Mailing Address - City:SOUTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075
Mailing Address - Country:US
Mailing Address - Phone:651-451-1277
Mailing Address - Fax:651-455-8488
Practice Address - Street 1:DENTAL SOUTH P A
Practice Address - Street 2:800 MARIE AVENUE
Practice Address - City:SOUTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075
Practice Address - Country:US
Practice Address - Phone:651-451-1277
Practice Address - Fax:651-455-8488
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist