Healthcare Provider Details

I. General information

NPI: 1659933620
Provider Name (Legal Business Name): JEREMIAH RICKETSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 FARMINGTON AVE
WEST HARTFORD CT
06107-2227
US

IV. Provider business mailing address

1011 N UNIVERSITY AVE
ANN ARBOR MI
48109-1078
US

V. Phone/Fax

Practice location:
  • Phone: 860-232-4606
  • Fax:
Mailing address:
  • Phone: 734-764-1568
  • Fax: 734-615-1415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2.013969
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: