Provider Demographics
NPI:1851481402
Name:JELICICH, ROBERT LEO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEO
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 1:5670 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1710
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5679
Mailing Address - Country:US
Mailing Address - Phone:323-930-2386
Mailing Address - Fax:323-930-2326
Practice Address - Street 1:5670 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1710
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-5679
Practice Address - Country:US
Practice Address - Phone:323-930-2386
Practice Address - Fax:323-930-2326
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice