Healthcare Provider Details

I. General information

NPI: 1952503765
Provider Name (Legal Business Name): MICHAEL E RISTY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13544 W. ROUTE 30 UNIT A
PLAINFIELD IL
60585
US

IV. Provider business mailing address

13544 W. ROUTE 30 UNIT A
PLAINFIELD IL
60585
US

V. Phone/Fax

Practice location:
  • Phone: 815-577-9000
  • Fax: 815-230-3900
Mailing address:
  • Phone: 815-577-9000
  • Fax: 815-230-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: