Basic Information
| Provider Information | |||||||||
| NPI: | 1740215573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0106X | 1496 | ND | Y | Dental Providers | Dentist | Oral and Maxillofacial Pathology |
ID Information
| ID | Type | State | Issuer | Description | ND200021 | 01 | ND | LHS # | OTHER | 40625 | 05 | ND | MEDICAID | DA9011026971 | 01 | ND | PREFERRED ONE # | OTHER | 6016 | 01 | ND | NDBS # | OTHER | 17823 | 05 | ND | MEDICAID | 4300108 | 01 | ND | MEDICA # | OTHER | 676707 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | 6864 | 01 | ND | SIOUX VALLEY # | OTHER | 8600254 | 01 | ND | MEDICA # | OTHER | HP38190 | 01 | ND | HEALTHPARTNERS # | OTHER | 271817100 | 05 | ND | MEDICAID | 61203HI | 01 | ND | MNBS # | OTHER |