Provider Demographics
NPI:1568074631
Name:CICCARELLI, HALEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:HALEY
Middle Name:
Last Name:CICCARELLI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 BRIDLE WAY
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2922
Mailing Address - Country:US
Mailing Address - Phone:610-717-8334
Mailing Address - Fax:
Practice Address - Street 1:3475 W CHESTER PIKE STE 220
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-4291
Practice Address - Country:US
Practice Address - Phone:610-717-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0428901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty