Healthcare Provider Details

I. General information

NPI: 1578646675
Provider Name (Legal Business Name): SHELLY LYNNE RICKERT DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 NEW BERN AVE NEW BERN RIDGE DENTAL CENTER
RALEIGH NC
27610-1821
US

IV. Provider business mailing address

118 BRUCE DRIVE
CARY NC
27511
US

V. Phone/Fax

Practice location:
  • Phone: 919-250-2930
  • Fax: 919-231-8077
Mailing address:
  • Phone: 919-467-8759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6459
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: