Basic Information
| Provider Information | |||||||||
| NPI: | 1841410727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZANINOVIC | ||||||||
| FirstName: | PERIZA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 123 MARMONT STREET | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129312190 | ||||||||
| FaxNumber: | 5128692940 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 MARMONT STREET | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129312190 | ||||||||
| FaxNumber: | 5128692940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 20101 | TX | N | Dental Providers | Dentist | General Practice | 1223G0001X | 473472 | CA | N | Dental Providers | Dentist | General Practice | 122300000X | 2901600691 | MI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 47342 | 01 | CA | STATE LICENSE NUMBER | OTHER |