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General NPI Number Information
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NPI Number | 1417766312
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Entity Type | Individual
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Provider Name | ELIZABETH BLANCA RICO RDH
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Gender | Female
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Dates
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Enumeration Date | 01/06/2025
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Last Update Date | 01/06/2025
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Provider Practice Location Address
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Address Line | 8475 SPARTA LINE RD NW STE C
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City | SPARTA
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State | MI
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Zip | 49345-8159
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Country | US
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Telephone | 866-988-4504
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Fax |
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Provider Business Mailing Address
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Address Line | 611 CROFTON ST SW
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-8029
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Country | US
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Telephone | 616-710-9409
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 2902017697
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License Number State | MI
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