Provider Demographics
NPI:1770070815
Name:RIKE, KELLI MARIE
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:RIKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-1607
Mailing Address - Country:US
Mailing Address - Phone:772-469-6909
Mailing Address - Fax:
Practice Address - Street 1:1323 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1607
Practice Address - Country:US
Practice Address - Phone:772-469-6909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN234831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice