Provider Demographics
NPI:1134835598
Name:DICICCIO, LUCAS JORDAN (DDS)
Entity type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:JORDAN
Last Name:DICICCIO
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 1:11378 N VIA MONTESSORI DR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-8839
Mailing Address - Country:US
Mailing Address - Phone:559-451-1873
Mailing Address - Fax:
Practice Address - Street 1:7055 N FRESNO ST STE 302
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2957
Practice Address - Country:US
Practice Address - Phone:559-325-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1050091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics