Provider Demographics
NPI:1326060633
Name:LICKTEIG, DAVID JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:LICKTEIG
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 1:4919 DOUGLAS AVE
Mailing Address - Street 2:STE. 10
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-2775
Mailing Address - Country:US
Mailing Address - Phone:515-278-2010
Mailing Address - Fax:515-278-1944
Practice Address - Street 1:4919 DOUGLAS AVE
Practice Address - Street 2:STE. 10
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-2775
Practice Address - Country:US
Practice Address - Phone:515-278-2010
Practice Address - Fax:515-278-1944
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA71801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice