Provider Demographics
NPI:1659368447
Name:HICKS, RILEY JARED (DDS)
Entity Type:Individual
Prefix:DR
First Name:RILEY
Middle Name:JARED
Last Name:HICKS
Suffix:
Gender:M
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:PO BOX 11606
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1606
Mailing Address - Country:US
Mailing Address - Phone:307-690-5990
Mailing Address - Fax:208-528-6399
Practice Address - Street 1:1255 ALLEN WAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002-8300
Practice Address - Country:US
Practice Address - Phone:307-690-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3314-OS1223S0112X
WY15061223S0112X
UT12550699-99251223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU91985Medicare UPIN