Provider Demographics
NPI:1669456364
Name:VICK, LATASHA (DDS)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:VICK
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 1:3011 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-2546
Mailing Address - Country:US
Mailing Address - Phone:620-231-9873
Mailing Address - Fax:620-231-2808
Practice Address - Street 1:2990 MILITARY AVE
Practice Address - Street 2:
Practice Address - City:BAXTER SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:66713-2331
Practice Address - Country:US
Practice Address - Phone:620-856-2900
Practice Address - Fax:620-856-2901
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1061723363A00000X, 363AM0700X
KS610681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1061723OtherPA LICENSE
OK200022980BMedicaid
OK200022980CMedicaid
37-1835Medicare ID - Type Unspecified
OK200022980CMedicaid