Provider Demographics
NPI:1619139730
Name:BICKNELL, BRIAN KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:BICKNELL
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 1:1881 S RANDALL RD STE D
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2532
Mailing Address - Country:US
Mailing Address - Phone:630-208-1779
Mailing Address - Fax:630-208-1824
Practice Address - Street 1:1881 S RANDALL RD STE D
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2532
Practice Address - Country:US
Practice Address - Phone:630-208-1779
Practice Address - Fax:630-208-1824
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018853122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist