Provider Demographics
NPI:1861899163
Name:SPOELSTRA, MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SPOELSTRA
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:NAVAL HEALTH CLINIC HAWAII
Mailing Address - Street 2:480 CENTRAL AVENUE
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HEALTH CLINIC HAWAII
Practice Address - Street 2:480 CENTRAL AVENUE
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860
Practice Address - Country:US
Practice Address - Phone:517-435-9914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021245122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist