Provider Demographics
NPI:1033126677
Name:LICIAGA, PABLO ENRIQUE (DDS)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:ENRIQUE
Last Name:LICIAGA
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 1:2115 BACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107
Mailing Address - Country:US
Mailing Address - Phone:619-224-2986
Mailing Address - Fax:619-224-2982
Practice Address - Street 1:2115 BACON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107
Practice Address - Country:US
Practice Address - Phone:619-224-2986
Practice Address - Fax:619-224-2982
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist