Provider Demographics
NPI:1376146746
Name:HICKS, TASJAH MONIQUE
Entity type:Individual
Prefix:
First Name:TASJAH
Middle Name:MONIQUE
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 77TH ST N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59402-7538
Mailing Address - Country:US
Mailing Address - Phone:406-731-2511
Mailing Address - Fax:
Practice Address - Street 1:21 77TH ST N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59402-7538
Practice Address - Country:US
Practice Address - Phone:406-731-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant