Provider Demographics
NPI:1003296831
Name:RICCIUTI, JESSE ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:ERIC
Last Name:RICCIUTI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 WELLNESS BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-7774
Mailing Address - Country:US
Mailing Address - Phone:704-291-7333
Mailing Address - Fax:704-292-1203
Practice Address - Street 1:1851 WELLNESS BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-7774
Practice Address - Country:US
Practice Address - Phone:704-291-7333
Practice Address - Fax:704-292-1203
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-07
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC94501223S0112X
NC115661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty