Healthcare Provider Details

I. General information

NPI: 1518021492
Provider Name (Legal Business Name): RONALD NICHOLAS MIZIKOW D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13727 S HURON RIVER DR
ROMULUS MI
48174-3628
US

IV. Provider business mailing address

13727 S HURON RIVER DR
ROMULUS MI
48174-3628
US

V. Phone/Fax

Practice location:
  • Phone: 734-941-0010
  • Fax: 734-941-0010
Mailing address:
  • Phone: 734-941-0010
  • Fax: 734-941-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number015137
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: