Provider Demographics
NPI:1952448078
Name:ILLICH, VANJA I
Entity Type:Individual
Prefix:DR
First Name:VANJA
Middle Name:I
Last Name:ILLICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4273 MONK RD
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-8610
Mailing Address - Country:US
Mailing Address - Phone:916-344-2554
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:5247 ELKHORN BLVD
Practice Address - Street 2:#C
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95842-2509
Practice Address - Country:US
Practice Address - Phone:916-344-2554
Practice Address - Fax:916-332-2472
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32421122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD32421Medicaid