Provider Demographics
NPI:1578758140
Name:ICKES, LIDIA B (DDS)
Entity Type:Individual
Prefix:DR
First Name:LIDIA
Middle Name:B
Last Name:ICKES
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:PO BOX 221360
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-0057
Mailing Address - Country:US
Mailing Address - Phone:248-245-0903
Mailing Address - Fax:
Practice Address - Street 1:55 S MAIN ST
Practice Address - Street 2:SUITE 241
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5372
Practice Address - Country:US
Practice Address - Phone:630-848-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 180151223G0001X
IL019.0282291223G0001X
MI29010195981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice