Provider Demographics
NPI:1679990501
Name:DENNIS LICHORWIC DMD PA
Entity Type:Organization
Organization Name:DENNIS LICHORWIC DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LICHORWIC
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-654-8665
Mailing Address - Street 1:4635 GULFSTARR DR
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5780
Mailing Address - Country:US
Mailing Address - Phone:850-654-8665
Mailing Address - Fax:850-654-9584
Practice Address - Street 1:4635 GULFSTARR DR
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5780
Practice Address - Country:US
Practice Address - Phone:850-654-8665
Practice Address - Fax:850-654-9584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0014608122300000X
FLDN19333122300000X
FLDN19829122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty