Provider Demographics
NPI:1134136823
Name:BUCCIGROSSI, PHILIP JR
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:BUCCIGROSSI
Suffix:JR
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 1:426 WOODROW RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1336
Mailing Address - Country:US
Mailing Address - Phone:718-966-8090
Mailing Address - Fax:718-984-3713
Practice Address - Street 1:426 WOODROW RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1336
Practice Address - Country:US
Practice Address - Phone:718-966-8090
Practice Address - Fax:718-984-3713
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY41607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01491854Medicaid