Provider Demographics
NPI:1346528692
Name:HICKEY, THOMAS MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:HICKEY
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 1:1202 S.E. PORT SAINT LUCIE BOULEVARD
Mailing Address - Street 2:FAMILY DENTISTRY
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-335-3088
Mailing Address - Fax:772-398-0041
Practice Address - Street 1:1202 S.E. PORT SAINT LUCIE BOULEVARD SUITE B
Practice Address - Street 2:FAMILY DENTISTRY
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-335-3088
Practice Address - Fax:772-398-0041
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist