Provider Demographics
NPI:1598767535
Name:NICKS, DENNIS BART (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:BART
Last Name:NICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 CANTERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7300
Mailing Address - Country:US
Mailing Address - Phone:910-343-0119
Mailing Address - Fax:910-343-8983
Practice Address - Street 1:2305 CANTERWOOD DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7300
Practice Address - Country:US
Practice Address - Phone:910-343-0119
Practice Address - Fax:910-343-8983
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261382086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC85769Medicare UPIN