Provider Demographics
NPI:1114060605
Name:HICKS, JAMES BUCHANAN JR (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BUCHANAN
Last Name:HICKS
Suffix:JR
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:P.O. BOX 5400
Mailing Address - Street 2:FEDERAL CORRECTIONAL COMPLEX VICTORVILLE
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301
Mailing Address - Country:US
Mailing Address - Phone:760-530-5168
Mailing Address - Fax:760-530-5177
Practice Address - Street 1:13777 AIR EXPRESSWAY BLVD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-0510
Practice Address - Country:US
Practice Address - Phone:760-530-5168
Practice Address - Fax:760-530-5177
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist