Provider Demographics
NPI:1558460410
Name:WICKER, MARYBETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARYBETH
Middle Name:
Last Name:WICKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 HUGUENOT ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113
Mailing Address - Country:US
Mailing Address - Phone:804-794-9789
Mailing Address - Fax:804-419-1059
Practice Address - Street 1:14001 CHARTER PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114
Practice Address - Country:US
Practice Address - Phone:804-379-1011
Practice Address - Fax:804-419-1059
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014102861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice