Provider Demographics
NPI:1629117338
Name:RICAFORT, ERWIN M (DENTIST)
Entity Type:Individual
Prefix:
First Name:ERWIN
Middle Name:M
Last Name:RICAFORT
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 WARD DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-0578
Mailing Address - Country:US
Mailing Address - Phone:615-890-0474
Mailing Address - Fax:615-890-0256
Practice Address - Street 1:1826 WARD DR
Practice Address - Street 2:SUITE 204
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-0578
Practice Address - Country:US
Practice Address - Phone:615-890-0474
Practice Address - Fax:615-890-0256
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS76631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice