Healthcare Provider Details

I. General information

NPI: 1023616596
Provider Name (Legal Business Name): RICCOBENE & ASSOCIATES I, DDS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 MIDWAY RD SE STE 116
BOLIVIA NC
28422-8377
US

IV. Provider business mailing address

PO BOX 749625
ATLANTA GA
30374-9625
US

V. Phone/Fax

Practice location:
  • Phone: 910-408-4436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL RICCOBENE
Title or Position: OWNER
Credential:
Phone: 919-853-6172