Provider Demographics
NPI:1861697559
Name:WICK, MARK WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WALTER
Last Name:WICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 HIGHWAY #71 WEST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:MO
Mailing Address - Zip Code:64485-1151
Mailing Address - Country:US
Mailing Address - Phone:816-324-5644
Mailing Address - Fax:816-324-6307
Practice Address - Street 1:803 HIGHWAY #71 WEST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:MO
Practice Address - Zip Code:64485-1151
Practice Address - Country:US
Practice Address - Phone:816-324-5644
Practice Address - Fax:816-324-6307
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO012833122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO28276OtherBNDD
MO1861697559Medicaid
MO1861697559Medicaid