Provider Demographics
NPI:1245751783
Name:STICE, MOLLY ELIZABETH (DMD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:STICE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 JUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4718
Mailing Address - Country:US
Mailing Address - Phone:217-371-0516
Mailing Address - Fax:
Practice Address - Street 1:2800 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4742
Practice Address - Country:US
Practice Address - Phone:618-474-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031168122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist