Healthcare Provider Details

I. General information

NPI: 1518525385
Provider Name (Legal Business Name): NICHOLAS RIZZO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LACKAWANNA AVE UNIT 107
SCRANTON PA
18503-2001
US

IV. Provider business mailing address

5 MARION CIR
OLYPHANT PA
18447-2227
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-4472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS042311
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: