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General NPI Number Information
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NPI Number | 1275951717
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Entity Type | Organization
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Legal Business Name | PANAMA CITY BEACH CENTER FOR COSMETIC & FAMILY DESTISTRY
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Dates
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Enumeration Date | 04/02/2014
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Last Update Date | 04/02/2014
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Provider Practice Location Address
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Address Line | 309 N RICHARD JACKSON BLVD
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32407-3695
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Country | US
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Telephone | 850-235-2299
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Fax | 850-334-9017
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Provider Business Mailing Address
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Address Line | 4635 GULFSTARR DR
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City | DESTIN
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State | FL
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Zip | 32541-5780
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Country | US
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Telephone | 850-654-8665
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Fax | 850-654-9584
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Authorized Official
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Title or Position | OWNER/ PRESIDENT
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Name | DR. DENNIS W LICHORWIC
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Credential | DMD
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Telephone | 850-654-8665
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN19333
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN19829
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0014608
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License Number State | FL
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