Provider Demographics
NPI:1598986416
Name:MICUCCI FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:MICUCCI FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MICUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:412-761-0202
Mailing Address - Street 1:704 LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15202
Mailing Address - Country:US
Mailing Address - Phone:412-761-0202
Mailing Address - Fax:412-761-0732
Practice Address - Street 1:704 LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15202
Practice Address - Country:US
Practice Address - Phone:412-761-0202
Practice Address - Fax:412-761-0732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026302L1223G0001X
PADS0281231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA594774OtherUNITED CONCORDIA DELTA DE