Provider Demographics
NPI:1952520751
Name:HICKORY FLAT ORTHODONTICS, PC
Entity Type:Organization
Organization Name:HICKORY FLAT ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PHD
Authorized Official - Phone:770-720-8138
Mailing Address - Street 1:6488 HICKORY FLAT HWY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-7235
Mailing Address - Country:US
Mailing Address - Phone:770-720-8138
Mailing Address - Fax:770-720-7580
Practice Address - Street 1:6488 HICKORY FLAT HWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-7235
Practice Address - Country:US
Practice Address - Phone:770-720-8138
Practice Address - Fax:770-720-7580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty