Healthcare Provider Details

I. General information

NPI: 1538748405
Provider Name (Legal Business Name): EMILY WICK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 EAST AVE STE 1
RED WING MN
55066-2567
US

IV. Provider business mailing address

1510 THOMAS LAKE POINTE RD APT 315
EAGAN MN
55122-2536
US

V. Phone/Fax

Practice location:
  • Phone: 651-388-1147
  • Fax:
Mailing address:
  • Phone: 952-846-9471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD14564
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: