Provider Demographics
NPI:1861576829
Name:SHORT, RICKY TODD (DDS DOCTOR OF DENTAL)
Entity type:Individual
Prefix:DR
First Name:RICKY
Middle Name:TODD
Last Name:SHORT
Suffix:
Gender:M
Credentials:DDS DOCTOR OF DENTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 S SONCY
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119
Mailing Address - Country:US
Mailing Address - Phone:806-374-8011
Mailing Address - Fax:806-356-0281
Practice Address - Street 1:3503 S SONCY
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119
Practice Address - Country:US
Practice Address - Phone:806-374-8011
Practice Address - Fax:806-356-0281
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX193511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice