Provider Demographics
NPI:1831228881
Name:TICZON, DAVID G (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:TICZON
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 1:15466 LOS GATOS BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2542
Mailing Address - Country:US
Mailing Address - Phone:408-358-8544
Mailing Address - Fax:
Practice Address - Street 1:15466 LOS GATOS BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2542
Practice Address - Country:US
Practice Address - Phone:408-358-8544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38930OtherCAILF. DENTAL LIC.