Provider Demographics
NPI:1750381208
Name:HICKS, KEVIN L (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
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 1:100 HIGHLANDS DR. SUITE 209
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543
Mailing Address - Country:US
Mailing Address - Phone:717-625-0596
Mailing Address - Fax:717-625-0809
Practice Address - Street 1:100 HIGHLANDS DR. SUITE 209
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543
Practice Address - Country:US
Practice Address - Phone:717-625-0596
Practice Address - Fax:717-625-0809
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001918798Medicaid