Provider Demographics
NPI:1962516054
Name:HOM, MICHAEL JAE (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAE
Last Name:HOM
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 1:2925 POST RD
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-6455
Mailing Address - Country:US
Mailing Address - Phone:715-341-1212
Mailing Address - Fax:715-341-0470
Practice Address - Street 1:2925 POST RD
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-6455
Practice Address - Country:US
Practice Address - Phone:715-341-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122351223G0001X
WI60961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice