Healthcare Provider Details

I. General information

NPI: 1073152146
Provider Name (Legal Business Name): JESSICA BEATRIZ RICCOBONO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 N MIAMI BEACH BLVD
NORTH MIAMI BEACH FL
33162-3701
US

IV. Provider business mailing address

2465 POINCIANA DR
WESTON FL
33327-1414
US

V. Phone/Fax

Practice location:
  • Phone: 954-681-2298
  • Fax:
Mailing address:
  • Phone: 954-681-2298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35873
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN24549
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: