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General NPI Number Information
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NPI Number | 1770070815
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Entity Type | Individual
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Provider Name | KELLI MARIE RIKE
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Gender | Female
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Dates
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Enumeration Date | 04/14/2018
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Last Update Date | 06/27/2023
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Provider Practice Location Address
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Address Line | 1323 N CENTRAL AVE
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City | SEBASTIAN
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State | FL
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Zip | 32958-1607
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Country | US
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Telephone | 772-469-6909
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Fax |
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Provider Business Mailing Address
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Address Line | 1323 N CENTRAL AVE
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City | SEBASTIAN
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State | FL
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Zip | 32958-1607
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Country | US
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Telephone | 772-469-6909
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Fax |
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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 | DN23483
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License Number State | FL
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