MEDICARE: MR. CHRISTOPHER FREDOLIN WICK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2004015365	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760469266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHRISTOPHER FREDOLIN WICK DDS

Provider Business Mailing Address
First Line	:	19323 W 63RD TERRACE
Second Line	:
City	:	SHAWNEE
State	:	KS
Zip	:	66218
Country	:	US
Telephone Number	:	913-269-5142
Fax Number	:	816-420-9052

Provider Business Practice Location Address
First Line	:	4910A NE 81ST ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64119-8400
Country	:	US
Telephone Number	:	816-420-9070
Fax Number	:	816-420-9052

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	11/01/2011

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