Healthcare Provider Details

I. General information

NPI: 1619169364
Provider Name (Legal Business Name): RONALD EUGENE MIZER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WEST MAIN CROSS
TAYLORVILLE IL
62568
US

IV. Provider business mailing address

400 WEST MAIN CROSS BOX 208
TAYLORVILLE IL
62568
US

V. Phone/Fax

Practice location:
  • Phone: 217-824-8232
  • Fax: 217-824-8521
Mailing address:
  • Phone: 217-824-8232
  • Fax: 217-824-8521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: