Healthcare Provider Details

I. General information

NPI: 1184647042
Provider Name (Legal Business Name): ROCCO CICCONE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 SOUTH LAPEAR RD.
LAKE ORION MI
48362
US

IV. Provider business mailing address

425 N PARK BLVD #200
LAKE ORION MI
48362-3189
US

V. Phone/Fax

Practice location:
  • Phone: 248-693-8366
  • Fax: 248-693-9240
Mailing address:
  • Phone: 248-693-8366
  • Fax: 248-693-9240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14885
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: