Healthcare Provider Details

I. General information

NPI: 1437687977
Provider Name (Legal Business Name): BRIAN WILLIAM JAMES CICERO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2837 LAFAYETTE RD
PORTSMOUTH NH
03801-5648
US

IV. Provider business mailing address

19 IDLEWOOD LN
KITTERY ME
03904-5515
US

V. Phone/Fax

Practice location:
  • Phone: 603-436-6997
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number04305
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: