Healthcare Provider Details

I. General information

NPI: 1417951781
Provider Name (Legal Business Name): MICHAEL JAY RAIZEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W 3RD ST
MANSFIELD OH
44906-2633
US

IV. Provider business mailing address

600 W 3RD ST
MANSFIELD OH
44906-2633
US

V. Phone/Fax

Practice location:
  • Phone: 419-522-1939
  • Fax:
Mailing address:
  • Phone: 419-522-1939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22695
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number106233
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: