Provider Demographics
NPI:1225123078
Name:RIDER, CYNTHIA A (DMD)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:A
Last Name:RIDER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 SPRING ARBOR RD.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203
Mailing Address - Country:US
Mailing Address - Phone:517-783-3130
Mailing Address - Fax:517-783-3140
Practice Address - Street 1:2545 SPRING ARBOR RD.
Practice Address - Street 2:SUITE 202
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203
Practice Address - Country:US
Practice Address - Phone:517-783-3130
Practice Address - Fax:517-783-3140
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010168091223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901016809OtherDELTA DENTAL
MI5386062OtherBCBS
MIOM96550Medicare ID - Type Unspecified