Healthcare Provider Details

I. General information

NPI: 1114301231
Provider Name (Legal Business Name): CHASE WICKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2015
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 1ST AVE NE STE 410
CEDAR RAPIDS IA
52402-4831
US

IV. Provider business mailing address

322 DENTAL SCIENCE BLDG S
IOWA CITY IA
52242-1001
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-1456
  • Fax:
Mailing address:
  • Phone: 319-335-7440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number09379
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: