Healthcare Provider Details

I. General information

NPI: 1568074631
Provider Name (Legal Business Name): HALEY CICCARELLI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 W CHESTER PIKE STE 220
NEWTOWN SQUARE PA
19073-4291
US

IV. Provider business mailing address

63 BRIDLE WAY
NEWTOWN SQUARE PA
19073-2922
US

V. Phone/Fax

Practice location:
  • Phone: 610-717-8334
  • Fax:
Mailing address:
  • Phone: 610-717-8334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS042890
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: