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General NPI Number Information
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NPI Number | 1891801585
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Entity Type | Individual
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Provider Name | JAMES L DERRICO DDS, LLC
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Gender | Male
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Dates
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Enumeration Date | 08/22/2006
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Last Update Date | 05/07/2023
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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 |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 1509
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License Number State | WY
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