Healthcare Provider Details

I. General information

NPI: 1912434523
Provider Name (Legal Business Name): JOSEPH CUCOLO D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PUNCHBOWL STREET QUEENS MEDICAL CENTER- DENTAL CLINIC
HONOLULU HI
96813
US

IV. Provider business mailing address

18 ST. GEORGE DR.
SHIRLEY NY
11967
US

V. Phone/Fax

Practice location:
  • Phone: 631-790-5506
  • Fax:
Mailing address:
  • Phone: 631-790-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDT-2702
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: