Provider Demographics
NPI:1730596024
Name:DARAIS, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DARAIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 VISTA PINON DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8619
Mailing Address - Country:US
Mailing Address - Phone:801-318-8615
Mailing Address - Fax:
Practice Address - Street 1:3 COUNTY ROAD 6523
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:NM
Practice Address - Zip Code:87417-9452
Practice Address - Country:US
Practice Address - Phone:505-598-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4137122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist