Provider Demographics
NPI:1154656361
Name:JUSTIN A. HICKS, D.M.D., PC
Entity Type:Organization
Organization Name:JUSTIN A. HICKS, D.M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:406-216-5273
Mailing Address - Street 1:1301 12TH AVE S
Mailing Address - Street 2:P.O. BOX 6408
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4600
Mailing Address - Country:US
Mailing Address - Phone:406-216-5273
Mailing Address - Fax:406-216-5274
Practice Address - Street 1:1301 12TH AVE S
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4600
Practice Address - Country:US
Practice Address - Phone:406-216-5273
Practice Address - Fax:406-216-5274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty