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General NPI Number Information
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NPI Number | 1235700014
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Entity Type | Organization
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Legal Business Name | JAMES L. DERRICO DDS LLC
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Dates
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Enumeration Date | 07/02/2021
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Last Update Date | 08/03/2023
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Provider Practice Location Address
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Address Line | 1130 S HWY 89
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City | JACKSON
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State | WY
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Zip | 83001-8512
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Country | US
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Telephone | 307-200-6644
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 806
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City | JACKSON
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State | WY
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Zip | 83001-0806
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Country | US
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Telephone | 630-399-7367
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JAMES L DERRICO
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Credential | DDS
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Telephone | 630-399-7367
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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