Provider Demographics
NPI:1225069818
Name:DIECIDUE, ROBERT J (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:DIECIDUE
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:909 WALNUT ST
Mailing Address - Street 2:3RD FLOOR, COB
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:215-955-6215
Mailing Address - Fax:215-923-9189
Practice Address - Street 1:909 WALNUT ST
Practice Address - Street 2:3RD FLOOR, COB
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-955-6215
Practice Address - Fax:215-923-9189
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026243L1223S0112X
PAMD421272204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012768190002Medicaid
PA024675RA9Medicare PIN
PAT30747Medicare UPIN