Provider Demographics
NPI:1275951717
Name:PANAMA CITY BEACH CENTER FOR COSMETIC & FAMILY DESTISTRY
Entity Type:Organization
Organization Name:PANAMA CITY BEACH CENTER FOR COSMETIC & FAMILY DESTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:LICHORWIC
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-654-8665
Mailing Address - Street 1:4635 GULFSTARR DR
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5780
Mailing Address - Country:US
Mailing Address - Phone:850-654-8665
Mailing Address - Fax:850-654-9584
Practice Address - Street 1:309 N RICHARD JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-3695
Practice Address - Country:US
Practice Address - Phone:850-235-2299
Practice Address - Fax:850-334-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0014608122300000X
FLDN19333122300000X
FLDN19829122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty