Provider Demographics
NPI:1710187240
Name:WICKFORD ORTHODONTICS, LLC
Entity type:Organization
Organization Name:WICKFORD ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:PALETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-295-2700
Mailing Address - Street 1:320 PHILLIPS ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-5149
Mailing Address - Country:US
Mailing Address - Phone:401-295-2700
Mailing Address - Fax:401-295-0008
Practice Address - Street 1:320 PHILLIPS ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5149
Practice Address - Country:US
Practice Address - Phone:401-295-2700
Practice Address - Fax:401-295-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty