MEDICARE: DR. RONALD DALE HICKERSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12662	TX

General Provider Information

NPI Number	:	1033268164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD DALE HICKERSON D.D.S.

Provider Business Mailing Address
First Line	:	5701 WOODWAY DR
Second Line	:	250
City	:	HOUSTON
State	:	TX
Zip	:	77057-1515
Country	:	US
Telephone Number	:	713-782-3123
Fax Number	:	713-278-1596

Provider Business Practice Location Address
First Line	:	5701 WOODWAY DR
Second Line	:	250
City	:	HOUSTON
State	:	TX
Zip	:	77057-1515
Country	:	US
Telephone Number	:	713-782-3123
Fax Number	:	713-278-1596

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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