Provider Demographics
NPI:1992228290
Name:MICHALAK, MARITZA ANDREINA (DMD)
Entity type:Individual
Prefix:
First Name:MARITZA
Middle Name:ANDREINA
Last Name:MICHALAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 N HILL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1912
Mailing Address - Country:US
Mailing Address - Phone:813-990-7449
Mailing Address - Fax:
Practice Address - Street 1:3575 PORTAGE RD STE A
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-6092
Practice Address - Country:US
Practice Address - Phone:574-349-2073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL229271223G0001X
IN12013318A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program