Provider Demographics
NPI:1053543405
Name:REZANIA, RAY
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:REZANIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 B SOUTH BROADWAY STREET
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914
Mailing Address - Country:US
Mailing Address - Phone:401-438-0200
Mailing Address - Fax:401-438-0211
Practice Address - Street 1:1055 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914
Practice Address - Country:US
Practice Address - Phone:401-438-0200
Practice Address - Fax:401-438-0211
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN02681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist