Provider Demographics
NPI:1972525434
Name:MEDOVIC, MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MEDOVIC
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 1:53 14TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3433
Mailing Address - Country:US
Mailing Address - Phone:304-232-2140
Mailing Address - Fax:304-232-4760
Practice Address - Street 1:53 14TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3433
Practice Address - Country:US
Practice Address - Phone:304-232-2140
Practice Address - Fax:304-232-4760
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice