Basic Information
Provider Information
NPI: 1225773781
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RIBEIRO PACHECO
FirstName: ALTAMIRO
MiddleName: FLAVIO
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 13318 CEDAR RD
Address2:  
City: CLEVELAND HEIGHTS
State: OH
PostalCode: 441182919
CountryCode: US
TelephoneNumber: 6892360241
FaxNumber:  
Practice Location
Address1: 4071 LEE RD STE 260
Address2:  
City: CLEVELAND
State: OH
PostalCode: 441282173
CountryCode: US
TelephoneNumber: 2167270234
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/29/2022
LastUpdateDate: 04/29/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 04/29/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001XRES.004449OHY Dental ProvidersDentistGeneral Practice

No ID Information.


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