Healthcare Provider Details

I. General information

NPI: 1366433062
Provider Name (Legal Business Name): MARY ELLEN CUCCARO D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 CHURCHLAND STREET EAST LIBERTY FAMILY HEALTH CARE CENTER
PITTSBURGH PA
15206
US

IV. Provider business mailing address

7171 CHURCHLAND STREET EAST LIBERTY FAMILY HEALTH CENTER
PITTSBURGH PA
15206
US

V. Phone/Fax

Practice location:
  • Phone: 412-361-8284
  • Fax: 412-361-8268
Mailing address:
  • Phone: 412-361-8284
  • Fax: 412-361-8268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS-029763-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: