Provider Demographics
NPI:1609851161
Name:HICKS, FREDERICK DEWITT (DMD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:DEWITT
Last Name:HICKS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-8806
Mailing Address - Country:US
Mailing Address - Phone:315-331-4530
Mailing Address - Fax:315-331-8305
Practice Address - Street 1:114 HIGH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-8806
Practice Address - Country:US
Practice Address - Phone:315-331-4530
Practice Address - Fax:315-331-8305
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0284581122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00452066Medicaid