Provider Demographics
NPI:1205047487
Name:CICCONE, RICHARD M (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:CICCONE
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 1:2778 HEWLETT AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-5037
Mailing Address - Country:US
Mailing Address - Phone:516-208-8608
Mailing Address - Fax:
Practice Address - Street 1:1757 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-2717
Practice Address - Country:US
Practice Address - Phone:516-623-1617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050868-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics