Provider Demographics
NPI:1922168335
Name:HICKS, THOMAS RANDAL (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RANDAL
Last Name:HICKS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:RANDAL
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:13305 NW CORNELL RD STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5987
Mailing Address - Country:US
Mailing Address - Phone:503-644-5433
Mailing Address - Fax:503-644-5436
Practice Address - Street 1:13305 NW CORNELL RD STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5987
Practice Address - Country:US
Practice Address - Phone:503-644-5433
Practice Address - Fax:503-644-5436
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1922168335Medicaid