Provider Demographics
NPI:1962623561
Name:SIP, MICHAEL ALAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
Last Name:SIP
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 1:110 N. KNIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510
Mailing Address - Country:US
Mailing Address - Phone:813-689-9623
Mailing Address - Fax:813-685-3731
Practice Address - Street 1:110 N. KNIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510
Practice Address - Country:US
Practice Address - Phone:813-689-9623
Practice Address - Fax:813-685-3731
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist