Healthcare Provider Details

I. General information

NPI: 1023019783
Provider Name (Legal Business Name): PATRICIA A PICCILLO D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date: 03/22/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

190 MUNSONHURST RD
FRANKLIN NJ
07416-1814
US

IV. Provider business mailing address

165 STATE LINE RD
WESTTOWN NY
10998-4106
US

V. Phone/Fax

Practice location:
  • Phone: 973-827-3976
  • Fax: 973-209-4518
Mailing address:
  • Phone: 845-726-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15803
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: