Provider Demographics
NPI:1720203227
Name:DESJARDIN, MICHAEL B (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:DESJARDIN
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 1:208 NW CANTON ST
Mailing Address - Street 2:
Mailing Address - City:JOHN DAY
Mailing Address - State:OR
Mailing Address - Zip Code:97845-1145
Mailing Address - Country:US
Mailing Address - Phone:541-575-2725
Mailing Address - Fax:
Practice Address - Street 1:208 NW CANTON ST
Practice Address - Street 2:
Practice Address - City:JOHN DAY
Practice Address - State:OR
Practice Address - Zip Code:97845-1145
Practice Address - Country:US
Practice Address - Phone:541-575-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD61631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice