Provider Demographics
NPI:1366925059
Name:PERSICKETTI, NICHOLAS GILBERT (DDS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GILBERT
Last Name:PERSICKETTI
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 1:212 N WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1224
Mailing Address - Country:US
Mailing Address - Phone:856-784-1540
Mailing Address - Fax:
Practice Address - Street 1:212 N WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1224
Practice Address - Country:US
Practice Address - Phone:856-784-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027221001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice