Provider Demographics
NPI:1881009520
Name:HICKMAN, SAMUEL JAMES (BSC BDENT)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JAMES
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:BSC BDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 DELAWARE ST SE
Mailing Address - Street 2:9-176 MOOS HEALTH SCIENCE TOWER
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0357
Mailing Address - Country:US
Mailing Address - Phone:612-229-9849
Mailing Address - Fax:
Practice Address - Street 1:515 DELAWARE ST SE
Practice Address - Street 2:9-176 MOOS HEALTH SCIENCE TOWER
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0357
Practice Address - Country:US
Practice Address - Phone:612-229-9849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR597122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist