Provider Demographics
NPI:1922635606
Name:FACCIOLO, JOHN (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FACCIOLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 THORNDALE DR
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-2332
Mailing Address - Country:US
Mailing Address - Phone:302-584-6088
Mailing Address - Fax:
Practice Address - Street 1:1304 N BROOM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-4266
Practice Address - Country:US
Practice Address - Phone:302-652-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DEG1-00114911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program