Healthcare Provider Details

I. General information

NPI: 1669911475
Provider Name (Legal Business Name): GALLUCCI DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 E MAIN ST
MARLTON NJ
08053-2157
US

IV. Provider business mailing address

24 E MAIN ST
MARLTON NJ
08053-2157
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-0546
  • Fax: 856-596-3093
Mailing address:
  • Phone: 856-983-0546
  • Fax: 856-596-3093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. LISA N GALLUCCI
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 856-983-0546