Provider Demographics
NPI:1073601316
Name:HICKMAN, STANLEY J (DMD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:J
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-9556
Mailing Address - Country:US
Mailing Address - Phone:478-992-9104
Mailing Address - Fax:478-992-9105
Practice Address - Street 1:275 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029-9556
Practice Address - Country:US
Practice Address - Phone:478-992-9104
Practice Address - Fax:478-992-9105
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0118651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000931422AMedicaid