Provider Demographics
NPI:1841368164
Name:RICCHETTI, PAUL A JR (DDS MSCD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:RICCHETTI
Suffix:JR
Gender:M
Credentials:DDS MSCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 LANDERBROOK DR
Mailing Address - Street 2:LANDERBROOK DENTAL PROFESSIONALS SUITE 221
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-6532
Mailing Address - Country:US
Mailing Address - Phone:440-461-6008
Mailing Address - Fax:440-461-9282
Practice Address - Street 1:5825 LANDERBROOK DR
Practice Address - Street 2:LANDERBROOK DENTAL PROFESSIONALS BLDG SUITE 221
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-6532
Practice Address - Country:US
Practice Address - Phone:440-461-6008
Practice Address - Fax:440-461-9282
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRI0504512Medicare ID - Type Unspecified
T47409Medicare UPIN