Provider Demographics
NPI:1518076264
Name:WICKS, KEVIN J (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:WICKS
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 1:2511 CORNING RD
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1047
Mailing Address - Country:US
Mailing Address - Phone:607-796-5985
Mailing Address - Fax:
Practice Address - Street 1:2860 WESTINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845
Practice Address - Country:US
Practice Address - Phone:607-796-2663
Practice Address - Fax:607-796-0064
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist