Provider Demographics
NPI:1699956664
Name:CICCIA, LORETTA A
Entity type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:A
Last Name:CICCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BENNINGTON ST
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128
Mailing Address - Country:US
Mailing Address - Phone:617-561-7600
Mailing Address - Fax:
Practice Address - Street 1:12 BENNINGTON ST
Practice Address - Street 2:FLOOR 2
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128
Practice Address - Country:US
Practice Address - Phone:617-561-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
9777881OtherMASS HEALTH