Provider Demographics
NPI:1588284046
Name:MAIZY, RITA
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:MAIZY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9266 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4046
Mailing Address - Country:US
Mailing Address - Phone:248-854-4638
Mailing Address - Fax:
Practice Address - Street 1:2792 PACKARD RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1932
Practice Address - Country:US
Practice Address - Phone:734-645-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600493122300000X, 1223G0001X
MI2901600493APP20122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist