Provider Demographics
NPI:1245306406
Name:IDICULLA, SEBU (DMD)
Entity type:Individual
Prefix:DR
First Name:SEBU
Middle Name:
Last Name:IDICULLA
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 1:5 SICOMAC RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:NORTH HALEDON
Mailing Address - State:NJ
Mailing Address - Zip Code:07508-2972
Mailing Address - Country:US
Mailing Address - Phone:973-423-3399
Mailing Address - Fax:973-423-4828
Practice Address - Street 1:5 SICOMAC RD
Practice Address - Street 2:SUITE 12
Practice Address - City:NORTH HALEDON
Practice Address - State:NJ
Practice Address - Zip Code:07508-2972
Practice Address - Country:US
Practice Address - Phone:973-423-3399
Practice Address - Fax:973-423-4828
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022415001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice