Provider Demographics
NPI:1083763759
Name:BUCCELLATO, VICTOR J (DMD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:J
Last Name:BUCCELLATO
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 1:507 STILLWELLS CORNER RD.
Mailing Address - Street 2:STE. D
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728
Mailing Address - Country:US
Mailing Address - Phone:732-462-0021
Mailing Address - Fax:732-462-1602
Practice Address - Street 1:507 STILLWELLS CORNER RD.
Practice Address - Street 2:STE. D
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728
Practice Address - Country:US
Practice Address - Phone:732-462-0021
Practice Address - Fax:732-462-1602
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017904001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice