Provider Demographics
NPI:1467844126
Name:DANIEL D WICOREK DDS INC
Entity Type:Organization
Organization Name:DANIEL D WICOREK DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DRISCOLL
Authorized Official - Last Name:WICOREK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-493-3705
Mailing Address - Street 1:3551 FARQUHAR AVE
Mailing Address - Street 2:101
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2003
Mailing Address - Country:US
Mailing Address - Phone:562-493-3705
Mailing Address - Fax:562-493-1572
Practice Address - Street 1:3551 FARQUHAR AVE
Practice Address - Street 2:101
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2003
Practice Address - Country:US
Practice Address - Phone:562-493-3705
Practice Address - Fax:562-493-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32657122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty