Provider Demographics
NPI:1841574258
Name:HICKMAN, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9485 MENTOR AVE 112
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8724
Mailing Address - Country:US
Mailing Address - Phone:440-255-8133
Mailing Address - Fax:
Practice Address - Street 1:1000 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1381
Practice Address - Country:US
Practice Address - Phone:614-258-3880
Practice Address - Fax:614-252-5873
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300235081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice