Provider Demographics
NPI:1770985475
Name:LOEW, MICHAEL D (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:LOEW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22D MEDICAL GROUP
Mailing Address - Street 2:57950 LEAVENWORTH ST
Mailing Address - City:MCCONNELL AFB
Mailing Address - State:KS
Mailing Address - Zip Code:67221-3506
Mailing Address - Country:US
Mailing Address - Phone:316-759-5181
Mailing Address - Fax:316-759-6277
Practice Address - Street 1:22D MEDICAL GROUP
Practice Address - Street 2:57950 LEAVENWORTH ST
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-5181
Practice Address - Fax:316-759-6277
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA091441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program