Provider Demographics
NPI:1497445936
Name:FICKES, DEREK JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:FICKES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12575 COLUMBIANA CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-9778
Mailing Address - Country:US
Mailing Address - Phone:330-501-4217
Mailing Address - Fax:
Practice Address - Street 1:309 S CHAPEL ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1612
Practice Address - Country:US
Practice Address - Phone:330-875-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.027190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program