Provider Demographics
NPI:1295892636
Name:VALLE, RICARDO T (DDS)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:T
Last Name:VALLE
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 1:2475 LAKELAND DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9505
Mailing Address - Country:US
Mailing Address - Phone:601-932-3393
Mailing Address - Fax:
Practice Address - Street 1:2475 LAKELAND DR
Practice Address - Street 2:SUITE G
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9505
Practice Address - Country:US
Practice Address - Phone:601-932-3393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1735-761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice