Provider Demographics
NPI:1164615084
Name:RILEY J. HICKS D.D.S., P.A.
Entity Type:Organization
Organization Name:RILEY J. HICKS D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RILEY
Authorized Official - Middle Name:JARED
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-528-6000
Mailing Address - Street 1:3905 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7596
Mailing Address - Country:US
Mailing Address - Phone:208-528-6000
Mailing Address - Fax:208-528-6399
Practice Address - Street 1:3905 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7596
Practice Address - Country:US
Practice Address - Phone:208-528-6000
Practice Address - Fax:208-528-6399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID33141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0025480Medicaid
MT0025480Medicaid