Provider Demographics
NPI:1073136933
Name:RIBOUL, REYNALDO CHRISTY (DMD)
Entity Type:Individual
Prefix:DR
First Name:REYNALDO
Middle Name:CHRISTY
Last Name:RIBOUL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GRANT ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1223
Mailing Address - Country:US
Mailing Address - Phone:347-217-7963
Mailing Address - Fax:
Practice Address - Street 1:12 GRANT ST UNIT 2
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-1223
Practice Address - Country:US
Practice Address - Phone:347-217-7963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858876122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN1858876OtherDENTAL LICENSE NUMBER