Provider Demographics
NPI:1861780355
Name:HICKS, DENISE GAYLE (DDS)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:GAYLE
Last Name:HICKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66855 FRYREAR RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-9193
Mailing Address - Country:US
Mailing Address - Phone:865-335-4571
Mailing Address - Fax:
Practice Address - Street 1:905 SW RIMROCK WAY STE 201
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2569
Practice Address - Country:US
Practice Address - Phone:541-526-5661
Practice Address - Fax:541-526-1441
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD95991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500641734Medicaid