Healthcare Provider Details

I. General information

NPI: 1205057056
Provider Name (Legal Business Name): PASQUALINO DICICCIO D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7104 N. FRESNO STREET SUITE 102
FRESNO CA
93720
US

IV. Provider business mailing address

7104 N. FRESNO STREET SUITE 102
FRESNO CA
93720
US

V. Phone/Fax

Practice location:
  • Phone: 559-225-2251
  • Fax: 559-490-2254
Mailing address:
  • Phone: 559-225-2251
  • Fax: 559-490-2254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS33920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: