Provider Demographics
NPI:1083642458
Name:RICKABAUGH, JEFF L (DDS, MDS, PA)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:L
Last Name:RICKABAUGH
Suffix:
Gender:M
Credentials:DDS, MDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 WESTBROOK PLAZA DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1355
Mailing Address - Country:US
Mailing Address - Phone:336-760-9229
Mailing Address - Fax:336-760-2263
Practice Address - Street 1:1551 WESTBROOK PLAZA DR
Practice Address - Street 2:SUITE 103
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1355
Practice Address - Country:US
Practice Address - Phone:336-760-9229
Practice Address - Fax:336-760-2263
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics