Provider Demographics
NPI:1962738286
Name:LICKTEIG, BENJAMIN (OD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:LICKTEIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 PROVIDENCE HWY
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-6806
Mailing Address - Country:US
Mailing Address - Phone:781-329-0067
Mailing Address - Fax:781-320-5603
Practice Address - Street 1:870 PROVIDENCE HWY
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-6806
Practice Address - Country:US
Practice Address - Phone:781-329-0067
Practice Address - Fax:781-320-5603
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist