Provider Demographics
NPI:1659310217
Name:WICKNICK, FREDRICK W (DMD)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:W
Last Name:WICKNICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3136 SQUALICUM PKWY
Mailing Address - Street 2:SUITE #B
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1954
Mailing Address - Country:US
Mailing Address - Phone:360-671-4859
Mailing Address - Fax:360-671-3010
Practice Address - Street 1:3136 SQUALICUM PKWY
Practice Address - Street 2:SUITE #B
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1954
Practice Address - Country:US
Practice Address - Phone:360-671-4859
Practice Address - Fax:360-671-3010
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006347204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA08367OtherWDS
WA581903OtherUNITED CONCORDIA
WA581903OtherUNITED CONCORDIA