Healthcare Provider Details

I. General information

NPI: 1588901169
Provider Name (Legal Business Name): ANTONINO GESUINO SECCHI DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 W LANCASTER AVE 2ND FLOOR
DEVON PA
19333-1589
US

IV. Provider business mailing address

229 W LANCASTER AVE 2ND FLOOR
DEVON PA
19333-1589
US

V. Phone/Fax

Practice location:
  • Phone: 484-580-8050
  • Fax: 484-580-8474
Mailing address:
  • Phone: 484-580-8050
  • Fax: 484-580-8474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS036679
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: