Healthcare Provider Details

I. General information

NPI: 1124147434
Provider Name (Legal Business Name): RIZALINO O YRAY JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W SADD ST
NORTH PRAIRIE WI
53153
US

IV. Provider business mailing address

205 W SADD STREET
NORTH PRAIRIE WI
53153-0404
US

V. Phone/Fax

Practice location:
  • Phone: 262-392-2244
  • Fax:
Mailing address:
  • Phone: 262-392-2244
  • Fax: 262-510-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4462015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: