Provider Demographics
NPI:1093971780
Name:HICKMAN, RUDOLPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:
Last Name:HICKMAN
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 1:200 ROSEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3709
Mailing Address - Country:US
Mailing Address - Phone:410-951-5083
Mailing Address - Fax:410-951-5082
Practice Address - Street 1:200 ROSEWOOD LN
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3709
Practice Address - Country:US
Practice Address - Phone:410-951-5083
Practice Address - Fax:410-951-5082
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05880122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentist