Provider Demographics
NPI:1710373451
Name:COLLEEN C HICKLE, DDS, INC.
Entity Type:Organization
Organization Name:COLLEEN C HICKLE, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GACKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-464-0500
Mailing Address - Street 1:3690 ORANGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4475
Mailing Address - Country:US
Mailing Address - Phone:216-464-0500
Mailing Address - Fax:216-464-0573
Practice Address - Street 1:3690 ORANGE PL STE 550
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4475
Practice Address - Country:US
Practice Address - Phone:216-464-0500
Practice Address - Fax:216-464-0573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2017-07-13
Deactivation Date:2015-04-20
Deactivation Code:
Reactivation Date:2017-07-13
Provider Licenses
StateLicense IDTaxonomies
OH21356261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental