Provider Demographics
NPI:1720102825
Name:DECICCO, MARY VERONICA (DMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:VERONICA
Last Name:DECICCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 TAMARACK CIR
Mailing Address - Street 2:
Mailing Address - City:SKILLMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08558-2019
Mailing Address - Country:US
Mailing Address - Phone:609-921-7744
Mailing Address - Fax:609-921-9508
Practice Address - Street 1:67 TAMARACK CIR
Practice Address - Street 2:
Practice Address - City:SKILLMAN
Practice Address - State:NJ
Practice Address - Zip Code:08558-2019
Practice Address - Country:US
Practice Address - Phone:609-921-7744
Practice Address - Fax:609-921-9508
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0123301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice