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DHMH : cdssearch: D12559

CDSPERMIT

D12559

APPLICANT_NAME

A F LACIVITA JR

APPLICANT_STATUS

NON RENEWED

CLASSIFICATION

PRACTITIONER

ADRESS

19330 GERMANTOWN RD

CITY

GERMANTOWN

COUNTY

 

ZIP

20874

STATE

MD

ADDRESS2

 

PROFESSION

DDS

LICENSE_ISSUEDDATE

7/1/1993 12:00 AM

LICENSE_EXPDATE

6/30/1995 12:00 AM

CURR_CERTIFICATION

Y

Attachments

Created at 11/21/2013 11:55 AM by System Account
Last modified at 11/21/2013 11:55 AM by System Account