Provider Demographics
NPI:1942262548
Name:ZICCARDI, VINCENT
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:ZICCARDI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BERGEN ST
Mailing Address - Street 2:ROOM B-854
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2495
Mailing Address - Country:US
Mailing Address - Phone:973-972-7462
Mailing Address - Fax:973-972-7322
Practice Address - Street 1:110 BERGEN ST
Practice Address - Street 2:ROOM B-854
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2495
Practice Address - Country:US
Practice Address - Phone:973-972-7462
Practice Address - Fax:973-972-7322
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06705100204E00000X
NJ22DI019979001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7827806Medicaid
NJU57371Medicare UPIN