Provider Demographics
NPI:1164036422
Name:HICKS, LOLITA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOLITA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 OLD SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1674
Mailing Address - Country:US
Mailing Address - Phone:979-220-6972
Mailing Address - Fax:
Practice Address - Street 1:1290 SALEM RD SW STE 10
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-4210
Practice Address - Country:US
Practice Address - Phone:979-220-6972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND144841223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice