Provider Demographics
NPI:1063712172
Name:CARMODY, RONALD JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:JAMES
Last Name:CARMODY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15647 NORDSTROM ST
Mailing Address - Street 2:P.O. BOX 9
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-8439
Mailing Address - Country:US
Mailing Address - Phone:906-524-6420
Mailing Address - Fax:
Practice Address - Street 1:15647 NORDSTROM ST
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-8439
Practice Address - Country:US
Practice Address - Phone:906-524-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020319122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist