Provider Demographics
NPI:1417766312
Name:RICO, ELIZABETH BLANCA (RDH)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BLANCA
Last Name:RICO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:BLANCA
Other - Middle Name:ELIZABETH
Other - Last Name:DUQUE-RICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:611 CROFTON ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-8029
Mailing Address - Country:US
Mailing Address - Phone:616-710-9409
Mailing Address - Fax:
Practice Address - Street 1:8475 SPARTA LINE RD NW STE C
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-8159
Practice Address - Country:US
Practice Address - Phone:866-988-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902017697124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist