MEDICARE: DR. LORETO R SICAM JR. DMD

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	39709	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39709	OTHER	CA	DENTAL LICENSE

General Provider Information

NPI Number	:	1336143189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORETO R SICAM JR. DMD

Provider Business Mailing Address
First Line	:	1290 VIA DI SALERNO
Second Line	:
City	:	PLEASANTON
State	:	CA
Zip	:	94566
Country	:	US
Telephone Number	:	925-600-7389
Fax Number	:

Provider Business Practice Location Address
First Line	:	699 LEWELLING BLVD
Second Line	:	STE 300
City	:	SAN LEANDRO
State	:	CA
Zip	:	94579
Country	:	US
Telephone Number	:	510-357-8960
Fax Number	:	510-357-8905

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	07/08/2007

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