Provider Demographics
NPI:1992809214
Name:HICKS, CHARLES MICHAEL (DDS MS)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:HICKS
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2234
Mailing Address - Country:US
Mailing Address - Phone:618-624-2500
Mailing Address - Fax:
Practice Address - Street 1:959 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2234
Practice Address - Country:US
Practice Address - Phone:618-624-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics