Provider Demographics
NPI:1538212725
Name:AMBROGIO, RICCARDO I (DMD)
Entity type:Individual
Prefix:DR
First Name:RICCARDO
Middle Name:I
Last Name:AMBROGIO
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 1:2928 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1007
Mailing Address - Country:US
Mailing Address - Phone:860-257-6994
Mailing Address - Fax:860-781-8215
Practice Address - Street 1:2928 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1007
Practice Address - Country:US
Practice Address - Phone:860-257-6994
Practice Address - Fax:860-781-8215
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT76781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U27378Medicare UPIN