Provider Demographics
NPI:1376737288
Name:GUDELLA S. LICAROS, DDS
Entity Type:Organization
Organization Name:GUDELLA S. LICAROS, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GUDELLA
Authorized Official - Middle Name:SAN JUAN
Authorized Official - Last Name:LICAROS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-787-2749
Mailing Address - Street 1:155 WEST 68TH STREET
Mailing Address - Street 2:SUITE 226
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5808
Mailing Address - Country:US
Mailing Address - Phone:212-787-2749
Mailing Address - Fax:
Practice Address - Street 1:155 W 68TH ST
Practice Address - Street 2:SUITE 226
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5808
Practice Address - Country:US
Practice Address - Phone:212-787-2749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043676261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental