Healthcare Provider Details

I. General information

NPI: 1205047487
Provider Name (Legal Business Name): RICHARD M CICCONE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1757 MERRICK AVE
MERRICK NY
11566-2717
US

IV. Provider business mailing address

2778 HEWLETT AVE
MERRICK NY
11566-5037
US

V. Phone/Fax

Practice location:
  • Phone: 516-623-1617
  • Fax:
Mailing address:
  • Phone: 516-208-8608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number050868-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: