Provider Demographics
NPI:1114364593
Name:REDISKE, MICHAEL RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RYAN
Last Name:REDISKE
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 1:300 TUSKEGEE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOVER AFB
Mailing Address - State:DE
Mailing Address - Zip Code:19902-5003
Mailing Address - Country:US
Mailing Address - Phone:302-677-2077
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:616-443-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-27
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010209181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice