Provider Demographics
NPI:1598429680
Name:RICCOBENE & ASSOCIATES CC, DDS, PC
Entity Type:Organization
Organization Name:RICCOBENE & ASSOCIATES CC, DDS, PC
Other - Org Name:COMMONWEALTH DENTISTRY - KENBRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCOBENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-853-6172
Mailing Address - Street 1:PO BOX 749632
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9632
Mailing Address - Country:US
Mailing Address - Phone:919-439-3331
Mailing Address - Fax:
Practice Address - Street 1:202 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:KENBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:23944-2040
Practice Address - Country:US
Practice Address - Phone:434-676-8023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty