Provider Demographics
NPI:1568120897
Name:WICKS, PRISCILLA LEE (CDA, BS, RDH)
Entity Type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:LEE
Last Name:WICKS
Suffix:
Gender:F
Credentials:CDA, BS, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 STONE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-2814
Mailing Address - Country:US
Mailing Address - Phone:508-944-2416
Mailing Address - Fax:
Practice Address - Street 1:5 KEITH WAY #3
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043
Practice Address - Country:US
Practice Address - Phone:781-608-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2530846124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist