Provider Demographics
NPI:1902958036
Name:DZIAK, RICHARD MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:DZIAK
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 1:2537 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:IN
Mailing Address - Zip Code:46360-1643
Mailing Address - Country:US
Mailing Address - Phone:219-872-1697
Mailing Address - Fax:
Practice Address - Street 1:605 W DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1438
Practice Address - Country:US
Practice Address - Phone:574-277-2220
Practice Address - Fax:574-277-8108
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009517A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist