Healthcare Provider Details

I. General information

NPI: 1174157945
Provider Name (Legal Business Name): ERIC CHICCONE MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 AVIATION BLVD
HERMOSA BEACH CA
90254-4024
US

IV. Provider business mailing address

1072 AVIATION BLVD
HERMOSA BEACH CA
90254-4024
US

V. Phone/Fax

Practice location:
  • Phone: 310-318-3333
  • Fax:
Mailing address:
  • Phone: 310-318-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number110954
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: