Healthcare Provider Details

I. General information

NPI: 1710232921
Provider Name (Legal Business Name): RI DDS (ADIL)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 OLIVE ST
PROVIDENCE RI
02906-1310
US

IV. Provider business mailing address

8 OLIVE ST
PROVIDENCE RI
02906-1310
US

V. Phone/Fax

Practice location:
  • Phone: 401-861-2001
  • Fax:
Mailing address:
  • Phone: 401-861-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberMD04710
License Number StateRI

VIII. Authorized Official

Name: MR. JOHN MICROULIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 401-222-3182