Healthcare Provider Details

I. General information

NPI: 1851287254
Provider Name (Legal Business Name): ANDREA MICHELLE RICCOBONO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

586 TREMONT ST
BOSTON MA
02118-1659
US

IV. Provider business mailing address

2465 POINCIANA DR
WESTON FL
33327-1414
US

V. Phone/Fax

Practice location:
  • Phone: 617-267-3334
  • Fax:
Mailing address:
  • Phone: 954-348-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN10001025
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: