Provider Demographics
NPI:1720621253
Name:BREZNAU, RICO MARIA
Entity Type:Individual
Prefix:
First Name:RICO
Middle Name:MARIA
Last Name:BREZNAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9293 SHELL RD
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-8525
Mailing Address - Country:US
Mailing Address - Phone:989-350-4686
Mailing Address - Fax:
Practice Address - Street 1:810 S MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2291
Practice Address - Country:US
Practice Address - Phone:989-350-4686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8133124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist