Provider Demographics
NPI:1023173788
Name:RISTUCCIA, JOHN MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:RISTUCCIA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BALSAM ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-7045
Mailing Address - Country:US
Mailing Address - Phone:508-999-6098
Mailing Address - Fax:
Practice Address - Street 1:46 BALSAM ST
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-7045
Practice Address - Country:US
Practice Address - Phone:508-999-6098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA115901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT90135Medicare UPIN
MAX03888OtherBLUE CROSS BLUE SHIELD
MA16420OtherHARVARD PILGRIM HEALTH CA
MA6591928OtherCIGNA HEALTHCARE
MAV04398OtherBLUE CROSS BLUE SHIELD
MA11590OtherDELTA DENTAL PLAN
MAX03888Medicare ID - Type UnspecifiedMEDICARE
MAT90135Medicare UPIN