Provider Demographics
NPI:1235700014
Name:JAMES L. DERRICO DDS LLC
Entity Type:Organization
Organization Name:JAMES L. DERRICO DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:DERRICO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-399-7367
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0806
Mailing Address - Country:US
Mailing Address - Phone:630-399-7367
Mailing Address - Fax:
Practice Address - Street 1:1130 S HWY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8512
Practice Address - Country:US
Practice Address - Phone:307-200-6644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-02
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental