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General NPI Number Information
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NPI Number | 1679790257
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Entity Type | Individual
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Provider Name | MARY LYNN LICHT D.D.S., D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 11924 W FOREST HILL BLVD STE 10
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City | WELLINGTON
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State | FL
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Zip | 33414-6200
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Country | US
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Telephone | 561-798-0825
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Fax | 561-795-9909
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Provider Business Mailing Address
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Address Line | 2284 ALFORD WAY
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City | WELLINGTON
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State | FL
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Zip | 33414-6200
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Country | US
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Telephone | 561-798-0825
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Fax | 561-795-9909
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 9660
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License Number State | FL
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