Provider Demographics
NPI:1861534950
Name:PATTY,LYBRAND & RICCIUTTI DDS PA
Entity type:Organization
Organization Name:PATTY,LYBRAND & RICCIUTTI DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL / OFFICE MANAGE
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-291-7333
Mailing Address - Street 1:1851 WELLNESS BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-7774
Mailing Address - Country:US
Mailing Address - Phone:704-291-7333
Mailing Address - Fax:704-292-1203
Practice Address - Street 1:10801 WOODLAND BEAVER RD STE 103
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5177
Practice Address - Country:US
Practice Address - Phone:704-291-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZN5322Medicaid
CO328400OtherTRIGON BCBS INS
NC96674OtherBLUE CROSS BLUE SHIELD NC
PA583212OtherUNITED CONCORDIA INS
NC8996674Medicaid
PA583212OtherUNITED CONCORDIA INS
NC96674OtherBLUE CROSS BLUE SHIELD NC
CO328400OtherTRIGON BCBS INS