Provider Demographics
NPI:1487769287
Name:RICALDE, PAT (DDS MD)
Entity type:Individual
Prefix:
First Name:PAT
Middle Name:
Last Name:RICALDE
Suffix:
Gender:F
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 N ARMENIA AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6451
Mailing Address - Country:US
Mailing Address - Phone:813-870-6000
Mailing Address - Fax:813-870-6015
Practice Address - Street 1:4200 N ARMENIA AVE STE 3
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6451
Practice Address - Country:US
Practice Address - Phone:813-870-6000
Practice Address - Fax:813-870-6015
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16594204E00000X
FLME88289174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075756001Medicaid