Provider Demographics
NPI:1376940668
Name:HICKAM, CECILIA JO (RDH-EA, OMT)
Entity Type:Individual
Prefix:MRS
First Name:CECILIA
Middle Name:JO
Last Name:HICKAM
Suffix:
Gender:F
Credentials:RDH-EA, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 E. STATE STREET
Mailing Address - Street 2:SUITE 102-D
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-584-9060
Mailing Address - Fax:
Practice Address - Street 1:1121 E. STATE STREET
Practice Address - Street 2:SUITE - 102-D
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-584-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDH-0356-EA124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist