MEDICARE: DR. ROBERT KENT RICKEY DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3280	OK

General Provider Information

NPI Number	:	1639104995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT KENT RICKEY DDS

Provider Business Mailing Address
First Line	:	104 PIEDMONT ROAD
Second Line	:	PO BOX 550
City	:	PIEDMONT
State	:	OK
Zip	:	73078
Country	:	US
Telephone Number	:	405-373-4566
Fax Number	:	405-378-1307

Provider Business Practice Location Address
First Line	:	104 PIEDMONT ROAD
Second Line	:
City	:	PIEDMONT
State	:	OK
Zip	:	73078
Country	:	US
Telephone Number	:	405-373-4566
Fax Number	:	405-378-1307

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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