Provider Demographics
NPI:1346515384
Name:KEYPORT DENTAL GROUP
Entity Type:Organization
Organization Name:KEYPORT DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ZICCHINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-714-1030
Mailing Address - Street 1:2407 BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT BORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-4334
Mailing Address - Country:US
Mailing Address - Phone:732-714-1030
Mailing Address - Fax:732-714-1142
Practice Address - Street 1:2407 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT BORO
Practice Address - State:NJ
Practice Address - Zip Code:08742-4334
Practice Address - Country:US
Practice Address - Phone:732-714-1030
Practice Address - Fax:732-714-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI20087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty