Provider Demographics
NPI:1053406132
Name:RISKO, KEVIN J (DMD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:RISKO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 PORTLAND PL
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-7705
Mailing Address - Country:US
Mailing Address - Phone:717-320-4963
Mailing Address - Fax:
Practice Address - Street 1:326 PORTLAND PL
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-7705
Practice Address - Country:US
Practice Address - Phone:717-320-4963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0392931223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102770945Medicaid
VTOVN1734Medicaid
VT0160001241OtherSTATE LICENSE
PADS039293OtherPA STATE LICENSE