Provider Demographics
NPI:1598053639
Name:RICCIARDONE, TANIA TRUTER (DMD)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:TRUTER
Last Name:RICCIARDONE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:TANIA
Other - Middle Name:TRUTER
Other - Last Name:RICCIARDONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:25 PADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-1117
Mailing Address - Country:US
Mailing Address - Phone:225-678-0568
Mailing Address - Fax:
Practice Address - Street 1:2727 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-2162
Practice Address - Country:US
Practice Address - Phone:251-473-5705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA61991223G0001X
AL63501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1861995Medicaid