Healthcare Provider Details

I. General information

NPI: 1497445936
Provider Name (Legal Business Name): DEREK JAMES FICKES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 07/23/2023
Certification Date: 07/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 S CHAPEL ST
LOUISVILLE OH
44641-1612
US

IV. Provider business mailing address

12575 COLUMBIANA CANFIELD RD
COLUMBIANA OH
44408-9778
US

V. Phone/Fax

Practice location:
  • Phone: 330-875-2200
  • Fax:
Mailing address:
  • Phone: 330-501-4217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.027190
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: