Provider Demographics
NPI:1104170620
Name:RIAZ, MAIMOONAH (RDH)
Entity type:Individual
Prefix:
First Name:MAIMOONAH
Middle Name:
Last Name:RIAZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26650 EUREKA RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4835
Mailing Address - Country:US
Mailing Address - Phone:734-941-4991
Mailing Address - Fax:734-941-4919
Practice Address - Street 1:26650 EUREKA RD
Practice Address - Street 2:SUITE C
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4835
Practice Address - Country:US
Practice Address - Phone:734-941-4991
Practice Address - Fax:734-941-4919
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016575124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist