Provider Demographics
NPI:1518682541
Name:RIVERSIDE DENTISTRY PLLC
Entity Type:Organization
Organization Name:RIVERSIDE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIN SUK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-730-2963
Mailing Address - Street 1:731 ABBEY MILL CT SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-7714
Mailing Address - Country:US
Mailing Address - Phone:734-730-2963
Mailing Address - Fax:
Practice Address - Street 1:207 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1607
Practice Address - Country:US
Practice Address - Phone:616-897-7179
Practice Address - Fax:616-897-7189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty