Provider Demographics
NPI:1487793469
Name:MIDDLETOWN DENTAL GROUP
Entity type:Organization
Organization Name:MIDDLETOWN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCCIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:513-423-0779
Mailing Address - Street 1:2402 CENTRAL AVE.
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-4692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2402 CENTRAL AVE.
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-4692
Practice Address - Country:US
Practice Address - Phone:513-423-0779
Practice Address - Fax:513-423-7731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0191911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty