Provider Demographics
NPI:1578646675
Name:RICKERT, SHELLY LYNNE (DDS)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:LYNNE
Last Name:RICKERT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BRUCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511
Mailing Address - Country:US
Mailing Address - Phone:919-467-8759
Mailing Address - Fax:
Practice Address - Street 1:2620 NEW BERN AVE
Practice Address - Street 2:NEW BERN RIDGE DENTAL CENTER
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1821
Practice Address - Country:US
Practice Address - Phone:919-250-2930
Practice Address - Fax:919-231-8077
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6459122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9001COtherBLUE CROSS BLUE SHIELD
NC899001CMedicaid