Healthcare Provider Details

I. General information

NPI: 1467417659
Provider Name (Legal Business Name): MICHAEL STEVEN CAPPUCCILLI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 SOMERDALE SQ
SOMERDALE NJ
08083-1345
US

IV. Provider business mailing address

844 N RINGGOLD ST
PHILADELPHIA PA
19130-1943
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-6016
  • Fax: 856-566-6012
Mailing address:
  • Phone: 215-232-2531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD121111
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: