Provider Demographics
NPI:1023274784
Name:STILLMAN, MICHELLE BANAGALE (DMD PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BANAGALE
Last Name:STILLMAN
Suffix:
Gender:F
Credentials:DMD PA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BUECHELE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:541 N DONNELLY STREET
Mailing Address - Street 2:
Mailing Address - City:MT. DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757
Mailing Address - Country:US
Mailing Address - Phone:352-383-8112
Mailing Address - Fax:
Practice Address - Street 1:541 N DONNELLY STREET
Practice Address - Street 2:
Practice Address - City:MT. DORA
Practice Address - State:FL
Practice Address - Zip Code:32757
Practice Address - Country:US
Practice Address - Phone:352-383-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18318122300000X
FLDN183181223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice