Provider Demographics
NPI:1790212504
Name:ICKES, ZACHARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:
Last Name:ICKES
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 1:3915 N TOWNSHIP ROAD 47
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-9542
Mailing Address - Country:US
Mailing Address - Phone:419-619-7360
Mailing Address - Fax:
Practice Address - Street 1:1601 N CLINTON ST
Practice Address - Street 2:SUITE A
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-8551
Practice Address - Country:US
Practice Address - Phone:419-956-0926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025040122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist