Provider Demographics
NPI:1629285119
Name:GUY A. AMICO JR. DMD, INC
Entity Type:Organization
Organization Name:GUY A. AMICO JR. DMD, INC
Other - Org Name:CLEAN SMILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAETANO
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:AMICO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-363-8885
Mailing Address - Street 1:370 HIGH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3631
Mailing Address - Country:US
Mailing Address - Phone:503-363-8885
Mailing Address - Fax:
Practice Address - Street 1:370 HIGH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3631
Practice Address - Country:US
Practice Address - Phone:503-363-8885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD47031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty