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General NPI Number Information
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NPI Number | 1316373756
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Entity Type | Organization
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Legal Business Name | MIDLAND FAMILY DENTAL CARE OF WYCKOFF, PA
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Dates
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Enumeration Date | 09/17/2013
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Last Update Date | 09/17/2013
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Provider Practice Location Address
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Address Line | 243 MORSE AVE
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City | WYCKOFF
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State | NJ
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Zip | 07481-1917
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Country | US
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Telephone | 201-485-8848
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Fax | 201-485-8851
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Provider Business Mailing Address
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Address Line | 243 MORSE AVE
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City | WYCKOFF
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State | NJ
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Zip | 07481-1917
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Country | US
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Telephone | 201-485-8848
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Fax | 201-485-8851
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Authorized Official
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Title or Position | PRESIDENT/GENERAL DENTIST
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Name | DR. FRED A PUCCIO
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Credential | DDS
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Telephone | 201-206-4097
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI01916200
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License Number State | NJ
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