Provider Demographics
NPI:1124208152
Name:NEGOM, RICUCCIO A (DDS)
Entity Type:Individual
Prefix:
First Name:RICUCCIO
Middle Name:A
Last Name:NEGOM
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 1:735 TANK FARM RD STE 170
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7071
Mailing Address - Country:US
Mailing Address - Phone:805-549-9000
Mailing Address - Fax:661-951-9847
Practice Address - Street 1:735 TANK FARM RD STE 170
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7071
Practice Address - Country:US
Practice Address - Phone:805-549-9000
Practice Address - Fax:805-549-9004
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55065122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist