Provider Demographics
NPI:1053584284
Name:MICHAEL R BAILEY MD DDS PA
Entity type:Organization
Organization Name:MICHAEL R BAILEY MD DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD DDS
Authorized Official - Phone:208-344-9115
Mailing Address - Street 1:403 S 11TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6968
Mailing Address - Country:US
Mailing Address - Phone:208-344-9115
Mailing Address - Fax:208-344-9113
Practice Address - Street 1:403 S 11TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6968
Practice Address - Country:US
Practice Address - Phone:208-344-9115
Practice Address - Fax:208-344-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3165/M63251223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1375019Medicare PIN