Provider Demographics
NPI:1356921142
Name:BROCCOLI, PETER J
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:BROCCOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71930
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-1930
Mailing Address - Country:US
Mailing Address - Phone:804-354-1600
Mailing Address - Fax:
Practice Address - Street 1:1807 HUGUENOT RD STE 120
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-5604
Practice Address - Country:US
Practice Address - Phone:804-354-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014194561223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery