Basic Information
| Provider Information | |||||||||
| NPI: | 1336898675 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RICCOBENE & ASSOCIATES LIII, DDS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 S BAXTER DR | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284510139 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 S BAXTER DR | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284510139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107691605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2022 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | MARLOW | ||||||||
| AuthorizedOfficialFirstName: | ANNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9192891857 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.