Provider Demographics
NPI:1750011144
Name:JELICICH, RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JELICICH
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 1:2009 8TH ST NW APT 303
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-5751
Mailing Address - Country:US
Mailing Address - Phone:916-605-9147
Mailing Address - Fax:
Practice Address - Street 1:2009 8TH ST NW APT 303
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-5751
Practice Address - Country:US
Practice Address - Phone:916-605-9147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL277921223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program