Provider Demographics
NPI:1023363108
Name:STICKA, SAMUEL JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOHN
Last Name:STICKA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 14TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3118
Mailing Address - Country:US
Mailing Address - Phone:701-483-3462
Mailing Address - Fax:701-483-4489
Practice Address - Street 1:239 14TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3118
Practice Address - Country:US
Practice Address - Phone:701-483-3462
Practice Address - Fax:701-483-4489
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND21351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice