Provider Demographics
NPI:1336143189
Name:SICAM, LORETO R JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LORETO
Middle Name:R
Last Name:SICAM
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 VIA DI SALERNO
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566
Mailing Address - Country:US
Mailing Address - Phone:925-600-7389
Mailing Address - Fax:
Practice Address - Street 1:699 LEWELLING BLVD
Practice Address - Street 2:STE 300
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94579
Practice Address - Country:US
Practice Address - Phone:510-357-8960
Practice Address - Fax:510-357-8905
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39709122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39709OtherDENTAL LICENSE