Provider Demographics
NPI:1689635781
Name:DUCIMO, JOHN N (DMO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:N
Last Name:DUCIMO
Suffix:
Gender:M
Credentials:DMO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01510-2556
Mailing Address - Country:US
Mailing Address - Phone:978-368-0340
Mailing Address - Fax:978-368-1719
Practice Address - Street 1:200 HIGH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MA
Practice Address - Zip Code:01510-2556
Practice Address - Country:US
Practice Address - Phone:978-368-0340
Practice Address - Fax:978-368-1719
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA169101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301071Medicaid