Healthcare Provider Details

I. General information

NPI: 1942673595
Provider Name (Legal Business Name): EZEQUIEL RIOS RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 STOCKING AVE NW
GRAND RAPIDS MI
49504-5176
US

IV. Provider business mailing address

669 STOCKING AVE NW
GRAND RAPIDS MI
49504-5176
US

V. Phone/Fax

Practice location:
  • Phone: 616-235-7507
  • Fax:
Mailing address:
  • Phone: 616-235-7507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902016085
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: