Provider Demographics
NPI:1841372257
Name:WICKS, RUSSELL A (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
Last Name:WICKS
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 1:910 MADISON AVE
Mailing Address - Street 2:STE 608
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38163-0001
Mailing Address - Country:US
Mailing Address - Phone:901-448-6476
Mailing Address - Fax:901-448-1390
Practice Address - Street 1:910 MADISON AVE
Practice Address - Street 2:STE 608
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-0001
Practice Address - Country:US
Practice Address - Phone:901-448-6476
Practice Address - Fax:901-448-1390
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3320122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist