Basic Information
Provider Information | |||||||||
NPI: | 1225069818 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIECIDUE | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD, MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 909 WALNUT ST | ||||||||
Address2: | 3RD FLOOR, COB | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191075211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159556215 | ||||||||
FaxNumber: | 2159239189 | ||||||||
Practice Location | |||||||||
Address1: | 909 WALNUT ST | ||||||||
Address2: | 3RD FLOOR, COB | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191075211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159556215 | ||||||||
FaxNumber: | 2159239189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 08/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | DS026243L | PA | N |   | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | MD421272 | PA | Y |   | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0012768190002 | 05 | PA |   | MEDICAID |