Healthcare Provider Details

I. General information

NPI: 1710187240
Provider Name (Legal Business Name): WICKFORD ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

320 PHILLIPS ST SUITE 202
NORTH KINGSTOWN RI
02852-5149
US

IV. Provider business mailing address

320 PHILLIPS ST SUITE 202
NORTH KINGSTOWN RI
02852-5149
US

V. Phone/Fax

Practice location:
  • Phone: 401-295-2700
  • Fax: 401-295-0008
Mailing address:
  • Phone: 401-295-2700
  • Fax: 401-295-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. STACI PALETTA
Title or Position: PARTNER
Credential: D.M.D.
Phone: 401-295-2700