MEDICARE: DR. JONATHAN I KALIKA D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D06367	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	909567	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1639230329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN I KALIKA D.M.D.

Provider Business Mailing Address
First Line	:	1545 E UNIVERSITY DR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85203-8132
Country	:	US
Telephone Number	:	480-834-9001
Fax Number	:	480-844-8206

Provider Business Practice Location Address
First Line	:	417 W CENTRAL AVE
Second Line	:
City	:	COOLIDGE
State	:	AZ
Zip	:	85228-4708
Country	:	US
Telephone Number	:	520-723-1111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	06/22/2016

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