Provider Demographics
NPI:1457035909
Name:RICO, TED
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:RICO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 W SEED FARM RD
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-5000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:483 W SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147-5000
Practice Address - Country:US
Practice Address - Phone:520-562-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD012413122300000X
IARES-30659390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist