Provider Demographics
NPI:1912092958
Name:HANLEY, MICHAEL RAYMOND (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:HANLEY
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 1:12702 HOGANS ALY
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2696
Mailing Address - Country:US
Mailing Address - Phone:804-530-3511
Mailing Address - Fax:
Practice Address - Street 1:13295 RIVERS BEND BLVD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-8610
Practice Address - Country:US
Practice Address - Phone:804-530-3539
Practice Address - Fax:804-530-5617
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006683122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA187470OtherANTHEM
VA812840OtherUNITED CONCORDIA NFS
VA9179583Medicaid