Provider Demographics
NPI:1922583426
Name:DAVID HICKEY DENTAL LLC
Entity Type:Organization
Organization Name:DAVID HICKEY DENTAL LLC
Other - Org Name:MAD RIVER FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SNIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-864-2341
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:ENON
Mailing Address - State:OH
Mailing Address - Zip Code:45323-0338
Mailing Address - Country:US
Mailing Address - Phone:937-864-2341
Mailing Address - Fax:937-864-1997
Practice Address - Street 1:7544 DAYTON SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-1902
Practice Address - Country:US
Practice Address - Phone:937-864-2341
Practice Address - Fax:937-864-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-01
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental