Healthcare Provider Details

I. General information

NPI: 1427118892
Provider Name (Legal Business Name): JOSEPH A CICCIO JR DDS AND PETER B DEMAREST DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E 77TH ST APT 1A
NEW YORK NY
10021-1823
US

IV. Provider business mailing address

1 PONDFIELD ROAD SUITE 304
BRONXVILLE NY
10708
US

V. Phone/Fax

Practice location:
  • Phone: 212-535-0515
  • Fax: 212-717-0527
Mailing address:
  • Phone: 914-337-4700
  • Fax: 914-395-1460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0457262
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0376242
License Number StateNY

VIII. Authorized Official

Name: DR. JOSEPH ANTHONY CICCIO JR.
Title or Position: OWNER
Credential: DDS
Phone: 914-337-4700