Provider Demographics
NPI:1730428749
Name:PUCILLO, MARIE CROSS (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:CROSS
Last Name:PUCILLO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARIE
Other - Middle Name:ELIZABETH
Other - Last Name:CROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:150 MALAGA ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-3521
Mailing Address - Country:US
Mailing Address - Phone:904-829-9024
Mailing Address - Fax:904-829-3546
Practice Address - Street 1:150 MALAGA ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-3521
Practice Address - Country:US
Practice Address - Phone:904-829-9024
Practice Address - Fax:904-829-3546
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN226671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program