Provider Demographics
NPI:1396210266
Name:HICKMAN, DUSTIN NIELSEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:NIELSEN
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 1:2046 JEWELL AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5308
Mailing Address - Country:US
Mailing Address - Phone:772-532-9879
Mailing Address - Fax:
Practice Address - Street 1:2437 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7964
Practice Address - Country:US
Practice Address - Phone:386-774-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL237911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice