Healthcare Provider Details

I. General information

NPI: 1164615084
Provider Name (Legal Business Name): RILEY J. HICKS D.D.S., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 WASHINGTON PKWY
IDAHO FALLS ID
83404-7596
US

IV. Provider business mailing address

3905 WASHINGTON PKWY
IDAHO FALLS ID
83404-7596
US

V. Phone/Fax

Practice location:
  • Phone: 208-528-6000
  • Fax: 208-528-6399
Mailing address:
  • Phone: 208-528-6000
  • Fax: 208-528-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3314
License Number StateID

VIII. Authorized Official

Name: DR. RILEY JARED HICKS
Title or Position: OWNER
Credential: D.D.S.
Phone: 208-528-6000