Provider Demographics
NPI:1467452482
Name:AMICO, GAETANO ANTHONY JR
Entity type:Individual
Prefix:DR
First Name:GAETANO
Middle Name:ANTHONY
Last Name:AMICO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GUY
Other - Middle Name:A
Other - Last Name:AMICO
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:3318 CHAMPIONSHIP DR. S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9712
Mailing Address - Country:US
Mailing Address - Phone:503-363-3009
Mailing Address - Fax:503-363-3009
Practice Address - Street 1:370 HIGH ST. NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-9701
Practice Address - Country:US
Practice Address - Phone:503-363-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD47031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice