Provider Demographics
NPI:1912402868
Name:MCDONALD, MICHAEL JUSTICE
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JUSTICE
Last Name:MCDONALD
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 1:2817 COUNTRY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1121
Mailing Address - Country:US
Mailing Address - Phone:425-457-9182
Mailing Address - Fax:
Practice Address - Street 1:3555 E US-412 HWY
Practice Address - Street 2:SUITE 30
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761
Practice Address - Country:US
Practice Address - Phone:210-956-0517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX357631223G0001X
NVLL463-181223G0001X
390200000X
AR46321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program