MEDICARE: RICK JEROME DEROVEN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	11795	MI

General Provider Information

NPI Number	:	1982627105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICK JEROME DEROVEN DDS

Provider Business Mailing Address
First Line	:	2340 S COMMERCE RD
Second Line	:	STE 1
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-2126
Country	:	US
Telephone Number	:	248-624-0676
Fax Number	:	248-624-8951

Provider Business Practice Location Address
First Line	:	2340 S COMMERCE RD
Second Line	:	STE 1
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-2126
Country	:	US
Telephone Number	:	248-624-0676
Fax Number	:	248-624-8951

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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