Provider Demographics
NPI:1487829545
Name:HICK, ALAN RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:RICHARD
Last Name:HICK
Suffix:
Gender:M
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:PO BOX 241
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48615-0241
Mailing Address - Country:US
Mailing Address - Phone:989-842-3151
Mailing Address - Fax:
Practice Address - Street 1:422 WEST CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MI
Practice Address - Zip Code:48615-0241
Practice Address - Country:US
Practice Address - Phone:989-842-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI132351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAH1826114Medicaid