Provider Demographics
NPI:1215024369
Name:GERALD T LICARI DDS PC
Entity Type:Organization
Organization Name:GERALD T LICARI DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:T
Authorized Official - Last Name:LICARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-374-8828
Mailing Address - Street 1:1032 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ODESSA
Mailing Address - State:MI
Mailing Address - Zip Code:48849-1004
Mailing Address - Country:US
Mailing Address - Phone:616-374-8828
Mailing Address - Fax:
Practice Address - Street 1:1032 4TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-1004
Practice Address - Country:US
Practice Address - Phone:616-374-8828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4057629Medicaid
MI11834OtherBLUE CROSS BLUE SHEILD