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General NPI Number Information
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NPI Number | 1659933620
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Entity Type | Individual
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Provider Name | JEREMIAH RICKETSON
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Gender | Male
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Dates
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Enumeration Date | 07/01/2019
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Last Update Date | 06/26/2025
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Provider Practice Location Address
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Address Line | 928 FARMINGTON AVE
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City | WEST HARTFORD
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State | CT
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Zip | 06107-2227
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Country | US
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Telephone | 860-232-4606
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Fax |
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Provider Business Mailing Address
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Address Line | 1011 N UNIVERSITY AVE
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City | ANN ARBOR
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State | MI
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Zip | 48109-1078
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Country | US
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Telephone | 734-764-1568
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Fax | 734-615-1415
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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 | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 2.013969
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License Number State | CT
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