Provider Demographics
NPI:1770625055
Name:PERSIANI, RICHARD J (DDS MS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:PERSIANI
Suffix:
Gender:M
Credentials:DDS MS
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6177 ORCHARD LAKE ROAD
Mailing Address - Street 2:STE #120
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:248-855-6655
Mailing Address - Fax:248-855-0803
Practice Address - Street 1:6177 ORCHARD LAKE ROAD
Practice Address - Street 2:SUITE #120
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-855-6655
Practice Address - Fax:248-855-0803
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MID10565122300000X
MI2901010565204E00000X, 1223S0112X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2758821Medicaid
P20352Medicare UPIN
MI2758821Medicaid