Provider Demographics
NPI:1972681914
Name:FUQUA, MICHAEL W (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:FUQUA
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 1:2202 S77 SUNSHINE STRIP
Mailing Address - Street 2:STE B
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550
Mailing Address - Country:US
Mailing Address - Phone:956-425-7474
Mailing Address - Fax:956-425-3555
Practice Address - Street 1:2202 S77 SUNSHINE STRIP
Practice Address - Street 2:STE B
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550
Practice Address - Country:US
Practice Address - Phone:956-425-7474
Practice Address - Fax:956-425-3555
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice