Provider Demographics
NPI:1235559410
Name:RIZZIELLO, DERRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:
Last Name:RIZZIELLO
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 1:949 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3838
Mailing Address - Country:US
Mailing Address - Phone:352-460-0164
Mailing Address - Fax:
Practice Address - Street 1:949 N 14TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3838
Practice Address - Country:US
Practice Address - Phone:352-460-0164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 205411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice