Provider Demographics
NPI:1497798292
Name:LALICK, AMY R (DDS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:LALICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-1849
Mailing Address - Country:US
Mailing Address - Phone:616-399-0200
Mailing Address - Fax:616-738-9127
Practice Address - Street 1:285 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-1849
Practice Address - Country:US
Practice Address - Phone:616-399-0200
Practice Address - Fax:616-738-9127
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010180651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4535594Medicaid
MIBC00473OtherBLUE CROSS BLUE SHEILD MI