Healthcare Provider Details

I. General information

NPI: 1710972898
Provider Name (Legal Business Name): CLAYTON GRAY HICKS SR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W PERIMETER RD
JB ANDREWS MD
20762-6602
US

IV. Provider business mailing address

1060 W PERIMETER RD
JB ANDREWS MD
20762-6602
US

V. Phone/Fax

Practice location:
  • Phone: 240-857-5029
  • Fax:
Mailing address:
  • Phone: 240-857-5029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3693
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10471
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: