MEDICARE: DR. MICHAEL JAY RAIZEN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	106233	CO
2	122300000X	Dentist	22695	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417951781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JAY RAIZEN D.D.S.

Provider Business Mailing Address
First Line	:	600 W 3RD ST
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2633
Country	:	US
Telephone Number	:	419-522-1939
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 W 3RD ST
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2633
Country	:	US
Telephone Number	:	419-522-1939
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	08/09/2010

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