1578646675 NPI number — MS. SHELLY LYNNE RICKERT DDS

Table of content: MS. SHELLY LYNNE RICKERT DDS (NPI 1578646675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578646675 NPI number — MS. SHELLY LYNNE RICKERT DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICKERT
Provider First Name:
SHELLY
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578646675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 BRUCE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-467-8759
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 NEW BERN AVE
Provider Second Line Business Practice Location Address:
NEW BERN RIDGE DENTAL CENTER
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-1821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-250-2930
Provider Business Practice Location Address Fax Number:
919-231-8077
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  6459 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9001C . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 899001C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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