Provider Demographics
NPI:1396016747
Name:BACCELLIERI, CARL EDWARD II (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:EDWARD
Last Name:BACCELLIERI
Suffix:II
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 COPE RD
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-2438
Mailing Address - Country:US
Mailing Address - Phone:610-444-0208
Mailing Address - Fax:610-444-0653
Practice Address - Street 1:630 COPE RD
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-2438
Practice Address - Country:US
Practice Address - Phone:610-444-0208
Practice Address - Fax:610-444-0653
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030182L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist