Provider Demographics
NPI:1528598299
Name:JELICICH, ALEXANDER ALBERT JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:ALBERT JOSEPH
Last Name:JELICICH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 BOYLSTON ST UNIT 1151
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3919
Mailing Address - Country:US
Mailing Address - Phone:916-605-9146
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5819
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857626122300000X, 1223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice