Healthcare Provider Details

I. General information

NPI: 1104629104
Provider Name (Legal Business Name): MARISSA BOCCHIARO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W PLEASANT AVE
MAYWOOD NJ
07607-1333
US

IV. Provider business mailing address

15-01 BROADWAY STE 10F
FAIR LAWN NJ
07410-6026
US

V. Phone/Fax

Practice location:
  • Phone: 201-518-3053
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI03124100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: