Provider Demographics
NPI:1568598290
Name:LICHORWIC, DENNIS
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:
Last Name:LICHORWIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4635 GULFSTARR DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541
Mailing Address - Country:US
Mailing Address - Phone:850-654-8665
Mailing Address - Fax:850-654-9584
Practice Address - Street 1:4635 GULFSTARR DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541
Practice Address - Country:US
Practice Address - Phone:850-654-8665
Practice Address - Fax:850-654-9584
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14608122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist