Provider Demographics
NPI:1538231527
Name:BEBEAU, MICHELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:BEBEAU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1566 125TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4749
Mailing Address - Country:US
Mailing Address - Phone:763-757-1535
Mailing Address - Fax:763-757-0805
Practice Address - Street 1:1566 125TH AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4749
Practice Address - Country:US
Practice Address - Phone:763-757-1535
Practice Address - Fax:763-757-0805
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice