Provider Demographics
NPI:1740215573
Name:HICKS, JOHN L (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:HICKS
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14961223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDND200021OtherLHS #
ND40625Medicaid
NDDA9011026971OtherPREFERRED ONE #
ND6016OtherNDBS #
ND17823Medicaid
ND4300108OtherMEDICA #
ND676707OtherAMERICA'S PPO/ARAZ #
ND6864OtherSIOUX VALLEY #
ND8600254OtherMEDICA #
NDHP38190OtherHEALTHPARTNERS #
ND271817100Medicaid
ND61203HIOtherMNBS #
NDDA9011026971OtherPREFERRED ONE #
ND61203HIOtherMNBS #