Healthcare Provider Details

I. General information

NPI: 1740456250
Provider Name (Legal Business Name): ALAN J. LICHT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18372 CLARK ST STE 201
TARZANA CA
91356-3550
US

IV. Provider business mailing address

18372 CLARK ST STE 201
TARZANA CA
91356-3550
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-5100
  • Fax:
Mailing address:
  • Phone: 818-996-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD21381
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: