Provider Demographics
NPI:1659592103
Name:FREDRICK W WICKNICK DMD INC PS
Entity Type:Organization
Organization Name:FREDRICK W WICKNICK DMD INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:WICKNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-671-4859
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000063471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA08367OtherWDS
WA581903OtherUNITED CONCORDIA
WA581903OtherUNITED CONCORDIA