Provider Demographics
NPI:1407902893
Name:HICKS, KATHERINE VASILIKI (DMD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:VASILIKI
Last Name:HICKS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:VASILIKI
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3545-1 ST. JOHNS BLUFF RD. S.
Mailing Address - Street 2:SUITE 352
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224
Mailing Address - Country:US
Mailing Address - Phone:904-998-7000
Mailing Address - Fax:904-998-7702
Practice Address - Street 1:630 ATLANTIC BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-4000
Practice Address - Country:US
Practice Address - Phone:904-247-2626
Practice Address - Fax:904-998-7702
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN171741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice