Provider Demographics
NPI:1609033018
Name:HICKS, HEATHER JEANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:JEANNE
Last Name:HICKS
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 1:4321 COLLEGE ST
Mailing Address - Street 2:P.O. BOX 276
Mailing Address - City:WOODBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46797-9005
Mailing Address - Country:US
Mailing Address - Phone:260-632-5312
Mailing Address - Fax:
Practice Address - Street 1:4321 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:IN
Practice Address - Zip Code:46797-9005
Practice Address - Country:US
Practice Address - Phone:260-632-5312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120096321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice