Provider Demographics
NPI:1184647042
Name:CICCONE, ROCCO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROCCO
Middle Name:
Last Name:CICCONE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 N PARK BLVD
Mailing Address - Street 2:#200
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-3189
Mailing Address - Country:US
Mailing Address - Phone:248-693-8366
Mailing Address - Fax:248-693-9240
Practice Address - Street 1:792 SOUTH LAPEAR RD.
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362
Practice Address - Country:US
Practice Address - Phone:248-693-8366
Practice Address - Fax:248-693-9240
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI148851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice