Healthcare Provider Details

I. General information

NPI: 1700869765
Provider Name (Legal Business Name): ROBERT J LICUL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 BRUSH HOLLOW RD
WESTBURY NY
11590-1778
US

IV. Provider business mailing address

959 BRUSH HOLLOW RD
WESTBURY NY
11590-1778
US

V. Phone/Fax

Practice location:
  • Phone: 516-333-5900
  • Fax: 516-333-5868
Mailing address:
  • Phone: 516-333-5900
  • Fax: 516-333-5868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number044656
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: