Provider Demographics
NPI:1619163045
Name:HICKMAN ORTHODONTIC
Entity Type:Organization
Organization Name:HICKMAN ORTHODONTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:317-888-7807
Mailing Address - Street 1:8001 SHELBY ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-5970
Mailing Address - Country:US
Mailing Address - Phone:317-888-7807
Mailing Address - Fax:317-888-0083
Practice Address - Street 1:8001 SHELBY ST
Practice Address - Street 2:SUITE #1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-5970
Practice Address - Country:US
Practice Address - Phone:317-888-7807
Practice Address - Fax:317-888-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty