Healthcare Provider Details

I. General information

NPI: 1225123078
Provider Name (Legal Business Name): CYNTHIA A RIDER D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 SPRING ARBOR RD. SUITE 202
JACKSON MI
49203
US

IV. Provider business mailing address

2545 SPRING ARBOR RD. SUITE 202
JACKSON MI
49203
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-3130
  • Fax: 517-783-3140
Mailing address:
  • Phone: 517-783-3130
  • Fax: 517-783-3140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901016809
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: