Healthcare Provider Details

I. General information

NPI: 1659017267
Provider Name (Legal Business Name): RAYFORD CHARLES ALVA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 M 139
BENTON HARBOR MI
49022-6103
US

IV. Provider business mailing address

1817 M 139
BENTON HARBOR MI
49022-6103
US

V. Phone/Fax

Practice location:
  • Phone: 269-487-3139
  • Fax:
Mailing address:
  • Phone: 630-272-5645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601408
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: