Provider Demographics
NPI:1942412374
Name:WALICKI, RICHARD J (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:WALICKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-3831
Mailing Address - Country:US
Mailing Address - Phone:215-634-7006
Mailing Address - Fax:215-634-7096
Practice Address - Street 1:2260 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-3831
Practice Address - Country:US
Practice Address - Phone:215-634-7006
Practice Address - Fax:215-634-7096
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026720L1223G0001X
CA424451223G0001X
NJ170291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice