Provider Demographics
NPI:1689102030
Name:DICICCO, JENNALEE (DMD)
Entity Type:Individual
Prefix:
First Name:JENNALEE
Middle Name:
Last Name:DICICCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JENNALEE
Other - Middle Name:
Other - Last Name:ERNST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1915
Mailing Address - Country:US
Mailing Address - Phone:551-996-2000
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601
Practice Address - Country:US
Practice Address - Phone:551-996-5593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program