Provider Demographics
NPI:1477835809
Name:ANDERSEN, MICHELLE RIACH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RIACH
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:RIACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1820 LANCASTER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1820 LANCASTER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-3584
Practice Address - Country:US
Practice Address - Phone:410-929-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2012-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15089122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist