MEDICARE: DR. VINCENT VISSICHELLI & ASSOCIATES, D.M.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	8363	NC

General Provider Information

NPI Number	:	1083037444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. VINCENT VISSICHELLI & ASSOCIATES, D.M.D., P.A.

Provider Business Mailing Address
First Line	:	213 SKYLAND PLAZA SUITE 1370-212
Second Line	:	FIREHOUSE KID'S DENTISTRY
City	:	SPRING LAKE
State	:	NC
Zip	:	28390
Country	:	US
Telephone Number	:	910-778-8485
Fax Number	:	910-778-8477

Provider Business Practice Location Address
First Line	:	2980 RAY ROAD
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390
Country	:	US
Telephone Number	:	910-778-8485
Fax Number	:	910-778-8477

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. VINCENT P. VISSIEHELLI
Credential	:	D.M.D., P.A.
Telephone Number	:	910-778-8485

Provider Enumeration Date	:	01/21/2014
Last Update Date	:	04/23/2014

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