Healthcare Provider Details

I. General information

NPI: 1508415100
Provider Name (Legal Business Name): RACHAEL M VASQUEZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RACHAEL DESLOOVER

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CHERRY ST SE
GRAND RAPIDS MI
49503-4748
US

IV. Provider business mailing address

449 PROSPECT AVE SE APT 1
GRAND RAPIDS MI
49503-5349
US

V. Phone/Fax

Practice location:
  • Phone: 734-635-9737
  • Fax:
Mailing address:
  • Phone: 734-635-9737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901600342
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: