Provider Demographics
NPI:1699855254
Name:BERTAGNOLLI, RICO LOUIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICO
Middle Name:LOUIS
Last Name:BERTAGNOLLI
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 1:921 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317-6515
Mailing Address - Country:US
Mailing Address - Phone:515-262-9581
Mailing Address - Fax:
Practice Address - Street 1:921 E 23RD ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-6515
Practice Address - Country:US
Practice Address - Phone:515-262-9581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA73771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2055251Medicaid