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General NPI Number Information
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NPI Number | 1215634266
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Entity Type | Organization
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Legal Business Name | RACINE PERIODONTICS AND IMPLANT DENTISTRY LTD
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Dates
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Enumeration Date | 02/09/2023
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Last Update Date | 02/09/2023
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Provider Practice Location Address
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Address Line | 255 HAVENWOOD DR
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City | LAKE GENEVA
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State | WI
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Zip | 53147-1988
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Country | US
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Telephone | 262-248-8505
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Fax |
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Provider Business Mailing Address
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Address Line | 4715 JAMES AVE
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City | RACINE
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State | WI
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Zip | 53402-2642
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Country | US
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Telephone | 305-807-9082
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ADRIAN RIVAS
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Credential | DMD
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Telephone | 305-807-9082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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