Provider Demographics
NPI:1184145625
Name:ANTONUCCIO, ANTHONY (DMD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ANTONUCCIO
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 1:1101 E HECTOR ST UNIT 421
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 LIMEKILN PIKE
Practice Address - Street 2:
Practice Address - City:DRESHER
Practice Address - State:PA
Practice Address - Zip Code:19025-1053
Practice Address - Country:US
Practice Address - Phone:215-643-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041399122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist