Provider Demographics
NPI:1649617093
Name:RICCIO, NICHOLAS VERTUCCI (DMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:VERTUCCI
Last Name:RICCIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4033
Mailing Address - Country:US
Mailing Address - Phone:630-805-2175
Mailing Address - Fax:
Practice Address - Street 1:3332 ROCHAMBEAU AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2836
Practice Address - Country:US
Practice Address - Phone:718-920-5997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL0210027551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program