Provider Demographics
NPI:1194161455
Name:SQUILLARO, RICHARD C (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:SQUILLARO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2546 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4638
Mailing Address - Country:US
Mailing Address - Phone:215-463-6677
Mailing Address - Fax:215-463-1077
Practice Address - Street 1:2546 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4638
Practice Address - Country:US
Practice Address - Phone:215-463-6677
Practice Address - Fax:215-463-1077
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017459L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics