Healthcare Provider Details

I. General information

NPI: 1962044560
Provider Name (Legal Business Name): RICCOBENE & ASSOCIATES XXXVI, DDS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 SHIPYARD BLVD STE 14
WILMINGTON NC
28403-8070
US

IV. Provider business mailing address

2250 SHIPYARD BLVD STE 14
WILMINGTON NC
28403-8070
US

V. Phone/Fax

Practice location:
  • Phone: 910-392-9101
  • Fax:
Mailing address:
  • Phone: 910-392-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SADE RENEE KEITH
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 919-238-6833