Provider Demographics
NPI:1518027580
Name:HICKMOTT, MARK THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:HICKMOTT
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 1:2410 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:SUITE 148
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1671
Mailing Address - Country:US
Mailing Address - Phone:925-855-1604
Mailing Address - Fax:925-855-0743
Practice Address - Street 1:2410 SAN RAMON VALLEY BLVD
Practice Address - Street 2:SUITE 148
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1671
Practice Address - Country:US
Practice Address - Phone:925-855-1604
Practice Address - Fax:925-855-0743
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA357301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680187966OtherTAX ID
UT14367OtherUNITED HEALTHCARE
PA766462OtherUNITED CONCORDIA