Healthcare Provider Details

I. General information

NPI: 1356106975
Provider Name (Legal Business Name): RICCOBENE & ASSOCIATES CC, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 THOMPSON ST STE I
ASHLAND VA
23005-1526
US

IV. Provider business mailing address

PO BOX 749632
ATLANTA GA
30374-9632
US

V. Phone/Fax

Practice location:
  • Phone: 804-798-2776
  • Fax:
Mailing address:
  • Phone: 919-585-5205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

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