Provider Demographics
NPI:1891801585
Name:DERRICO, JAMES L (DDS, LLC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:DERRICO
Suffix:
Gender:M
Credentials:DDS, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0806
Mailing Address - Country:US
Mailing Address - Phone:630-399-7367
Mailing Address - Fax:
Practice Address - Street 1:1130 S HWY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8512
Practice Address - Country:US
Practice Address - Phone:307-200-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1509122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7191950001Medicare NSC