Provider Demographics
NPI:1679790257
Name:LICHT, MARY LYNN (DDS, DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:LICHT
Suffix:
Gender:F
Credentials:DDS, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2284 ALFORD WAY
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6200
Mailing Address - Country:US
Mailing Address - Phone:561-798-0825
Mailing Address - Fax:561-795-9909
Practice Address - Street 1:11924 W FOREST HILL BLVD STE 10
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6200
Practice Address - Country:US
Practice Address - Phone:561-798-0825
Practice Address - Fax:561-795-9909
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL96601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL576405OtherUNITED CONCORDIA
FL67438OtherB.C.B.S. OF FLA