=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861780355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENISE GAYLE HICKS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2011
-----------------------------------------------------
Last Update Date | 12/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 SW RIMROCK WAY STE 201
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97756-2569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-526-5661
-----------------------------------------------------
Fax | 541-526-1441
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66855 FRYREAR RD
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97703-9193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-335-4571
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D9599
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------