MEDICARE: KEYPORT DENTAL GROUP

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	122300000X	Dentist	DI20087	NJ

General Provider Information

NPI Number	:	1346515384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEYPORT DENTAL GROUP

Provider Business Mailing Address
First Line	:	2407 BRIDGE AVE
Second Line	:
City	:	POINT PLEASANT BORO
State	:	NJ
Zip	:	08742-4334
Country	:	US
Telephone Number	:	732-714-1030
Fax Number	:	732-714-1142

Provider Business Practice Location Address
First Line	:	2407 BRIDGE AVE
Second Line	:
City	:	POINT PLEASANT BORO
State	:	NJ
Zip	:	08742-4334
Country	:	US
Telephone Number	:	732-714-1030
Fax Number	:	732-714-1142

Authorized Official
Title or Position	:	OWNER
Name	:	JOSEPH RICHARD ZICCHINO
Credential	:	DDS
Telephone Number	:	732-714-1030

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	03/08/2012

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