Provider Demographics
NPI:1780879981
Name:HICKMAN, JERRY RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:RICHARD
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 SHELBY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-5970
Mailing Address - Country:US
Mailing Address - Phone:317-888-7807
Mailing Address - Fax:317-888-0083
Practice Address - Street 1:8001 SHELBY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-5970
Practice Address - Country:US
Practice Address - Phone:317-888-7807
Practice Address - Fax:317-888-0083
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006199A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics