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General NPI Number Information
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NPI Number | 1457867483
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Entity Type | Organization
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Legal Business Name | JOSEPH M. LICUL, DDS, P.C.
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Dates
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Enumeration Date | 12/28/2017
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Last Update Date | 12/28/2017
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Provider Practice Location Address
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Address Line | 8 N MAIN ST
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City | SOUTHAMPTON
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State | NY
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Zip | 11968-3308
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Country | US
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Telephone | 631-283-6591
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Fax |
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Provider Business Mailing Address
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Address Line | 8 N MAIN ST
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City | SOUTHAMPTON
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State | NY
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Zip | 11968-3308
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Country | US
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Telephone | 631-283-6591
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOSEPH M LICUL
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Credential | DDS
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Telephone | 917-686-2712
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 37608
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License Number State | NY
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