MEDICARE: DR. JOHN R LICKING 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	1223G0001X	General Practice Dentistry	21321	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21321	OTHER	CA	CA

General Provider Information

NPI Number	:	1376524140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN R LICKING DDS

Provider Business Mailing Address
First Line	:	730 ALTOS OAKS DR
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94024-5401
Country	:	US
Telephone Number	:	408-736-6255
Fax Number	:	408-736-6100

Provider Business Practice Location Address
First Line	:	730 ALTOS OAKS DR
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94024-5401
Country	:	US
Telephone Number	:	408-736-6255
Fax Number	:	408-736-6100

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

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	09/10/2024

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Directions to “ DR. JOHN R LICKING DDS” Practice Location

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