=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790157881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICCOBENE & ASSOCIATES XII, DDS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2015
-----------------------------------------------------
Last Update Date | 10/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 NW MAYNARD ROAD
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-975-0626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1203 NW MAYNARD ROAD
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE COORDINATOR
-----------------------------------------------------
Name | NICOLE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-975-0626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------