Provider Demographics
NPI:1295395960
Name:RIABOWOL, LUCAS
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:RIABOWOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-3800
Mailing Address - Country:US
Mailing Address - Phone:908-642-5125
Mailing Address - Fax:
Practice Address - Street 1:1 HOWELL RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3800
Practice Address - Country:US
Practice Address - Phone:908-642-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-16
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02758600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist