Provider Demographics
NPI:1376524140
Name:LICKING, JOHN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:LICKING
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:1565 HOLLENBECK AVE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-5922
Mailing Address - Country:US
Mailing Address - Phone:408-736-6255
Mailing Address - Fax:408-736-6100
Practice Address - Street 1:1565 HOLLENBECK AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-5922
Practice Address - Country:US
Practice Address - Phone:408-736-6255
Practice Address - Fax:408-736-6100
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA213211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21321OtherCA