Healthcare Provider Details

I. General information

NPI: 1083037444
Provider Name (Legal Business Name): DR. VINCENT VISSICHELLI & ASSOCIATES, D.M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2980 RAY ROAD
SPRING LAKE NC
28390
US

IV. Provider business mailing address

213 SKYLAND PLAZA SUITE 1370-212 FIREHOUSE KID'S DENTISTRY
SPRING LAKE NC
28390
US

V. Phone/Fax

Practice location:
  • Phone: 910-778-8485
  • Fax: 910-778-8477
Mailing address:
  • Phone: 910-778-8485
  • Fax: 910-778-8477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8363
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. VINCENT P. VISSIEHELLI
Title or Position: DOCTOR
Credential: D.M.D., P.A.
Phone: 910-778-8485