Provider Demographics
NPI:1205301777
Name:HICKORY HILLS DENTAL CARE LLC
Entity type:Organization
Organization Name:HICKORY HILLS DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-766-8800
Mailing Address - Street 1:1947 FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-2729
Mailing Address - Country:US
Mailing Address - Phone:256-766-8800
Mailing Address - Fax:256-766-8936
Practice Address - Street 1:1947 FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-2729
Practice Address - Country:US
Practice Address - Phone:256-766-8800
Practice Address - Fax:256-766-8936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL207491Medicaid