Provider Demographics
NPI:1205042322
Name:CALICDAN, CAROL S (DDS)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:S
Last Name:CALICDAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3681
Mailing Address - Country:US
Mailing Address - Phone:909-981-5083
Mailing Address - Fax:909-981-4213
Practice Address - Street 1:1227 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3681
Practice Address - Country:US
Practice Address - Phone:909-981-5083
Practice Address - Fax:909-981-4213
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49732122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist