Basic Information
| Provider Information | |||||||||
| NPI: | 1578646675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKERT | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 BRUCE DRIVE | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194678759 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2620 NEW BERN AVE | ||||||||
| Address2: | NEW BERN RIDGE DENTAL CENTER | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192502930 | ||||||||
| FaxNumber: | 9192318077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 6459 | NC | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 9001C | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 899001C | 05 | NC | MEDICAID |