Provider Demographics
NPI:1700928801
Name:GALLUCCI, LISA N (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:N
Last Name:GALLUCCI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2157
Mailing Address - Country:US
Mailing Address - Phone:856-983-0546
Mailing Address - Fax:856-596-3093
Practice Address - Street 1:24 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2157
Practice Address - Country:US
Practice Address - Phone:856-983-0546
Practice Address - Fax:856-596-3093
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NJ22D1021745001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies