Provider Demographics
NPI:1902309685
Name:ARIZA, RICHARD BRIAN
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRIAN
Last Name:ARIZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BEAVERDALE LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2507
Mailing Address - Country:US
Mailing Address - Phone:917-519-6063
Mailing Address - Fax:
Practice Address - Street 1:6855 S 27TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8045
Practice Address - Country:US
Practice Address - Phone:414-435-0787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD390200000X
WI10019441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program