Healthcare Provider Details

I. General information

NPI: 1568813780
Provider Name (Legal Business Name): CAROLINA CUCCO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 MARTIN LUTHER KING JR BLVD
DETROIT MI
48208-2576
US

IV. Provider business mailing address

322 DENTAL SCIENCE BLDG S
IOWA CITY IA
52242-1001
US

V. Phone/Fax

Practice location:
  • Phone: 313-494-6931
  • Fax:
Mailing address:
  • Phone: 319-335-7440
  • Fax: 319-335-7451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2952000362
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: