Healthcare Provider Details

I. General information

NPI: 1891625265
Provider Name (Legal Business Name): RICCOBENE & ASSOCIATES CCCI, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 HIGHWAY 17 S STE C
NORTH MYRTLE BEACH SC
29582-1904
US

IV. Provider business mailing address

PO BOX 749625
ATLANTA GA
30374-9625
US

V. Phone/Fax

Practice location:
  • Phone: 843-491-6021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL RICCOBENE
Title or Position: CEO
Credential: DDS
Phone: 910-853-6172