Provider Demographics
NPI:1174025894
Name:STATEN ISLAND DENTISTRY P.C.
Entity Type:Organization
Organization Name:STATEN ISLAND DENTISTRY P.C.
Other - Org Name:STATEN ISLAND DENTISTRY P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:DICICCO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-698-1885
Mailing Address - Street 1:979 WILLOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6520
Mailing Address - Country:US
Mailing Address - Phone:718-698-1885
Mailing Address - Fax:
Practice Address - Street 1:979 WILLOWBROOK RD.
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-698-1885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental