Provider Demographics
NPI:1891997490
Name:WICKFORD ORTHODONTICS
Entity Type:Organization
Organization Name:WICKFORD ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RADTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-295-2700
Mailing Address - Street 1:320 PHILLIPS ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-5149
Mailing Address - Country:US
Mailing Address - Phone:401-295-2700
Mailing Address - Fax:
Practice Address - Street 1:320 PHILLIPS ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5149
Practice Address - Country:US
Practice Address - Phone:401-295-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI0028941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISW60095Medicaid
RIWO60094Medicaid