Provider Demographics
NPI:1366691917
Name:HICKS, SHANNON KATHLEEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:HICKS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ZEAGLER DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3883
Mailing Address - Country:US
Mailing Address - Phone:386-325-6000
Mailing Address - Fax:386-325-9306
Practice Address - Street 1:800 ZEAGLER DR
Practice Address - Street 2:SUITE 330
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3883
Practice Address - Country:US
Practice Address - Phone:386-325-6000
Practice Address - Fax:386-325-9306
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN135411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice