Provider Demographics
NPI:1518171727
Name:LICHTENSTEIN, JEROME LELAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:LELAND
Last Name:LICHTENSTEIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2708
Mailing Address - Country:US
Mailing Address - Phone:860-889-1011
Mailing Address - Fax:860-889-5569
Practice Address - Street 1:113 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2708
Practice Address - Country:US
Practice Address - Phone:860-889-1011
Practice Address - Fax:860-889-5569
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT37551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery