Provider Demographics
NPI:1982627105
Name:DEROVEN, RICK JEROME (DDS)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:JEROME
Last Name:DEROVEN
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 1:2340 S COMMERCE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2126
Mailing Address - Country:US
Mailing Address - Phone:248-624-0676
Mailing Address - Fax:248-624-8951
Practice Address - Street 1:2340 S COMMERCE RD
Practice Address - Street 2:STE 1
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-2126
Practice Address - Country:US
Practice Address - Phone:248-624-0676
Practice Address - Fax:248-624-8951
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11795122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist