Provider Demographics
NPI:1619169364
Name:MIZER, RONALD EUGENE (DDS)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:EUGENE
Last Name:MIZER
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 1:400 WEST MAIN CROSS
Mailing Address - Street 2:BOX 208
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568
Mailing Address - Country:US
Mailing Address - Phone:217-824-8232
Mailing Address - Fax:217-824-8521
Practice Address - Street 1:400 WEST MAIN CROSS
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568
Practice Address - Country:US
Practice Address - Phone:217-824-8232
Practice Address - Fax:217-824-8521
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist