=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912434523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH CUCOLO D.D.S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2017
-----------------------------------------------------
Last Update Date | 01/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 PUNCHBOWL STREET QUEENS MEDICAL CENTER- DENTAL CLINIC
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-790-5506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 ST. GEORGE DR.
-----------------------------------------------------
City | SHIRLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-790-5506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DT-2702
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------