Provider Demographics
NPI:1669445730
Name:LICAROS, GUDELLA SAN JUAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GUDELLA
Middle Name:SAN JUAN
Last Name:LICAROS
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 1:2135 NOLL DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603
Mailing Address - Country:US
Mailing Address - Phone:717-397-7625
Mailing Address - Fax:717-397-6057
Practice Address - Street 1:2135 NOLL DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603
Practice Address - Country:US
Practice Address - Phone:717-397-7625
Practice Address - Fax:717-397-6057
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0436761223G0001X
PADS037692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice