Provider Demographics
NPI:1134399892
Name:RICUCCIO A. NEGOM DDS, A PROFESSIOAL DENTAL CORPORATION
Entity type:Organization
Organization Name:RICUCCIO A. NEGOM DDS, A PROFESSIOAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DIRECTOR, OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RICUCCIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:NEGOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-215-3349
Mailing Address - Street 1:44725 10TH ST W STE 160
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3000
Mailing Address - Country:US
Mailing Address - Phone:661-942-8555
Mailing Address - Fax:
Practice Address - Street 1:735 TANK FARM RD STE 170
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7071
Practice Address - Country:US
Practice Address - Phone:805-549-9000
Practice Address - Fax:805-549-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-09
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55065261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental