Provider Demographics
NPI:1457077828
Name:LICA, STEPHANIE (RDH, BSDH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LICA
Suffix:
Gender:F
Credentials:RDH, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38415 LANCASTER ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1523
Mailing Address - Country:US
Mailing Address - Phone:734-536-0618
Mailing Address - Fax:
Practice Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:313-494-6939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist