1619750494 NPI number — RICCOBENE & ASSOCIATES CCC, DDS, PC

Table of content: (NPI 1619750494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619750494 NPI number — RICCOBENE & ASSOCIATES CCC, DDS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICCOBENE & ASSOCIATES CCC, DDS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RICCOBENE & ASSOCIATES FAMILY DENTISTRY - FORT MILL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619750494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 749625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-9625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
839-895-3753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 FORT MILL PARKWAY STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-491-6021
Provider Business Practice Location Address Fax Number:
839-895-3753
Provider Enumeration Date:
08/16/2023

Additional Information

Authorized Official

Authorized Official Last Name:
RICCOBENE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
855-417-4226

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com