Provider Demographics
NPI:1346502465
Name:PRATHER, MICHELLE (DMD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PRATHER
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 1:35TH MEDICAL GROUP - MISAWA AIR BASE
Mailing Address - Street 2:UNIT 5024, BUILDING 99
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319
Mailing Address - Country:US
Mailing Address - Phone:618-960-9065
Mailing Address - Fax:
Practice Address - Street 1:35TH MEDICAL GROUP - MISAWA AIR BASE
Practice Address - Street 2:UNIT 5024, BUILDING 99
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319
Practice Address - Country:US
Practice Address - Phone:618-960-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028636122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-028636OtherIL LICENSE