Provider Demographics
NPI:1932219474
Name:LICHSTRAHL, JARED EVAN (DMD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:EVAN
Last Name:LICHSTRAHL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N UNIVERSITY DR
Mailing Address - Street 2:STE#12
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-3003
Mailing Address - Country:US
Mailing Address - Phone:954-741-6400
Mailing Address - Fax:954-741-0105
Practice Address - Street 1:2500 N UNIVERSITY DR
Practice Address - Street 2:STE#12
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322-3003
Practice Address - Country:US
Practice Address - Phone:954-741-6400
Practice Address - Fax:954-741-0105
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN143281223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics