Provider Demographics
NPI:1023019783
Name:PICCILLO, PATRICIA A (DMD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:A
Last Name:PICCILLO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:WESTTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10998-4106
Mailing Address - Country:US
Mailing Address - Phone:845-726-3806
Mailing Address - Fax:
Practice Address - Street 1:190 MUNSONHURST RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NJ
Practice Address - Zip Code:07416-1814
Practice Address - Country:US
Practice Address - Phone:973-827-3976
Practice Address - Fax:973-209-4518
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2017-03-02
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
NJ158031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice