Healthcare Provider Details

I. General information

NPI: 1760477186
Provider Name (Legal Business Name): CHARLES EDWARD NOCCO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 FRONT ST
ELMER NJ
08318-2177
US

IV. Provider business mailing address

PO BOX 617
ELMER NJ
08318-0617
US

V. Phone/Fax

Practice location:
  • Phone: 856-358-8303
  • Fax: 856-358-9145
Mailing address:
  • Phone: 856-858-8303
  • Fax: 856-358-9145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22D100832300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDSO16237L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: