Provider Demographics
NPI:1053323311
Name:WICKS, ROBERT DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DANIEL
Last Name:WICKS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4352 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-9132
Mailing Address - Country:US
Mailing Address - Phone:330-296-4745
Mailing Address - Fax:330-296-4745
Practice Address - Street 1:4352 LOVERS LN
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-9132
Practice Address - Country:US
Practice Address - Phone:330-296-4745
Practice Address - Fax:330-296-4745
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH119301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice