Provider Demographics
NPI:1083875694
Name:VICELJA, JOHN LOUIS (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LOUIS
Last Name:VICELJA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1711 VIA EL PRADO
Mailing Address - Street 2:303
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5714
Mailing Address - Country:US
Mailing Address - Phone:310-792-4833
Mailing Address - Fax:310-792-4837
Practice Address - Street 1:1711 VIA EL PRADO
Practice Address - Street 2:303
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5714
Practice Address - Country:US
Practice Address - Phone:310-792-4833
Practice Address - Fax:310-792-4837
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA333961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice