# GERALD T LICARI DDS PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215024369
- **Authorized official:** DR. GERALD T LICARI DDS (PRESIDENT)
- **Authorized official phone:** (616) 374-8828

## Contact information

- **Practice address:** 1032 4TH AVE, LAKE ODESSA, MI 48849-1004
- **Practice address phone:** (616) 374-8828
- **Mailing address:** 1032 4TH AVE, LAKE ODESSA, MI 48849-1004
- **Mailing address phone:** (616) 374-8828

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 2901011834 | MI | Yes |

## Other

- **Enumeration date:** 10/09/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 11834 | BLUE CROSS BLUE SHEILD | MI |
| 05 | — | 4057629 | — | MI |