Provider Demographics
NPI:1821005117
Name:VORLICKY, GERALD W (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:W
Last Name:VORLICKY
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 1:780 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1617
Mailing Address - Country:US
Mailing Address - Phone:208-888-4711
Mailing Address - Fax:208-888-0308
Practice Address - Street 1:780 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1617
Practice Address - Country:US
Practice Address - Phone:208-888-4711
Practice Address - Fax:208-888-0308
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD14661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID10012304OtherREGENCE BLUE SHIELD OF ID
ID65037OtherBLUE CROSS OF IDAHO
ID134932OtherTRI-CARE
IDD1466OtherDELTA DENTAL OF ID