MEDICARE: DR. SALVATORE JOSEPH LICATA JR. DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3058	NV
2	122300000X	Dentist	36391	CA

General Provider Information

NPI Number	:	1063427789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALVATORE JOSEPH LICATA JR. DDS

Provider Business Mailing Address
First Line	:	7720 W SAHARA AVE
Second Line	:	SUITE 110
City	:	LAS VEGAS
State	:	NV
Zip	:	89117
Country	:	US
Telephone Number	:	702-255-8000
Fax Number	:	702-255-8355

Provider Business Practice Location Address
First Line	:	7720 W SAHARA AVE
Second Line	:	SUITE 110
City	:	LAS VEGAS
State	:	NV
Zip	:	89117
Country	:	US
Telephone Number	:	702-255-8000
Fax Number	:	702-255-8355

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	07/08/2007

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