Basic Information
| Provider Information | |||||||||
| NPI: | 1588044721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STICKA DENTAL CLINIC, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 239 14TH ST W | ||||||||
| Address2: | |||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014833462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 239 14TH ST W | ||||||||
| Address2: | |||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014833462 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2015 | ||||||||
| LastUpdateDate: | 06/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | STICKA | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7014833462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 2135 | ND | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.