Provider Demographics
NPI:1114301603
Name:HICKS, TYLER JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JAMES
Last Name:HICKS
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 1:9008 S SCHOFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-5801
Mailing Address - Country:US
Mailing Address - Phone:801-386-6377
Mailing Address - Fax:
Practice Address - Street 1:9008 S SCHOFIELD CIR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-5801
Practice Address - Country:US
Practice Address - Phone:801-386-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9428569-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist