Provider Demographics
NPI:1861668360
Name:CIVILLICO, JOHN N (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:N
Last Name:CIVILLICO
Suffix:
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 1:626 BURMONT RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-3827
Mailing Address - Country:US
Mailing Address - Phone:610-352-6560
Mailing Address - Fax:484-466-3132
Practice Address - Street 1:626 BURMONT RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-3827
Practice Address - Country:US
Practice Address - Phone:610-352-6560
Practice Address - Fax:484-466-3132
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037196122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102132422Medicaid