Individual
LATASHA VICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
2990 MILITARY AVE, BAXTER SPRINGS, KS 66713-2331
(620) 856-2900
(620) 856-2901
Mailing address
3011 N MICHIGAN ST, PITTSBURG, KS 66762-2546
(620) 231-9873
(620) 231-2808
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
61068
KS
363A00000X
Physician Assistant
1061723
OK
363AM0700X
Medical Physician Assistant
1061723
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1061723
PA LICENSE
OK
05
—
200022980B
—
OK
05
—
200022980C
—
OK
Enumeration date
12/06/2005
Last updated
08/20/2013
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