Provider Demographics
NPI:1609965599
Name:RICO, JORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:RICO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9390 BIG HORN BLVD
Mailing Address - Street 2:SUITE #130
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7978
Mailing Address - Country:US
Mailing Address - Phone:916-684-8200
Mailing Address - Fax:916-684-8258
Practice Address - Street 1:9390 BIG HORN BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758
Practice Address - Country:US
Practice Address - Phone:916-684-8200
Practice Address - Fax:916-684-8258
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47412122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist