Provider Demographics
NPI:1083770465
Name:WICKERSHAM, GEORGE THOMAS
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:THOMAS
Last Name:WICKERSHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 CROSS TIMBERES RD
Mailing Address - Street 2:STE A
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028
Mailing Address - Country:US
Mailing Address - Phone:972-874-2800
Mailing Address - Fax:972-539-0165
Practice Address - Street 1:2260 CROSS TIMBERES RD
Practice Address - Street 2:STE A
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:972-874-2800
Practice Address - Fax:972-539-0165
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX178751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry