Basic Information
| Provider Information | |||||||||
| NPI: | 1881214203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIZK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 WEEOT WAY | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074870215 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 N INDIAN RD | ||||||||
| Address2: | |||||||||
| City: | SMITH RIVER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955679509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074870215 | ||||||||
| FaxNumber: | 7074873003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2020 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | DN25037 | FL | Y | Dental Providers | Dentist |
No ID Information.