Provider Demographics
NPI:1700869765
Name:LICUL, ROBERT J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:LICUL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 BRUSH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1778
Mailing Address - Country:US
Mailing Address - Phone:516-333-5900
Mailing Address - Fax:516-333-5868
Practice Address - Street 1:959 BRUSH HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-1778
Practice Address - Country:US
Practice Address - Phone:516-333-5900
Practice Address - Fax:516-333-5868
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0446561223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02071410Medicaid
NYU80973Medicare UPIN
NYD40001Medicare ID - Type Unspecified