Provider Demographics
NPI:1659933620
Name:RICKETSON, JEREMIAH
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:RICKETSON
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 1:1011 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1078
Mailing Address - Country:US
Mailing Address - Phone:734-764-1568
Mailing Address - Fax:734-615-1415
Practice Address - Street 1:928 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2227
Practice Address - Country:US
Practice Address - Phone:860-232-4606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2.0139691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery