Provider Demographics
NPI:1215582655
Name:RICCIARDI, MICHAEL CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:RICCIARDI
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 1:1930 MARLTON PIKE E STE K53
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-4107
Mailing Address - Country:US
Mailing Address - Phone:856-424-2500
Mailing Address - Fax:
Practice Address - Street 1:1930 MARLTON PIKE E STE K53
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-4107
Practice Address - Country:US
Practice Address - Phone:856-424-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ027690122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist