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General NPI Number Information
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NPI Number | 1578677175
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Entity Type | Individual
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Provider Name | DOMENIC RICCOBONO DDS
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Gender | Male
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Dates
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Enumeration Date | 08/19/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 42 KINDERHOOK ST
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City | CHATHAM
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State | NY
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Zip | 12037-1207
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Country | US
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Telephone | 518-392-5231
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Fax | 518-392-7339
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Provider Business Mailing Address
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Address Line | 42 KINDERHOOK ST
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City | CHATHAM
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State | NY
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Zip | 12037-1207
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Country | US
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Telephone | 518-392-5231
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Fax | 518-392-7339
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 045941
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License Number State | NY
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