Provider Demographics
NPI:1528428976
Name:BROWN, MICHAEL WAYNE
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:BROWN
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 1:1395 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-1768
Mailing Address - Country:US
Mailing Address - Phone:781-963-6077
Mailing Address - Fax:
Practice Address - Street 1:1395 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-1768
Practice Address - Country:US
Practice Address - Phone:781-963-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-27
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857254122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program