Provider Demographics
NPI:1790157881
Name:RICCOBENE & ASSOCIATES XII, DDS, P.A.
Entity Type:Organization
Organization Name:RICCOBENE & ASSOCIATES XII, DDS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-975-0626
Mailing Address - Street 1:1203 NW MAYNARD ROAD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1203 NW MAYNARD ROAD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513
Practice Address - Country:US
Practice Address - Phone:919-975-0626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental