Healthcare Provider Details

I. General information

NPI: 1205301777
Provider Name (Legal Business Name): HICKORY HILLS DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 FLORENCE BLVD
FLORENCE AL
35630-2729
US

IV. Provider business mailing address

1947 FLORENCE BLVD
FLORENCE AL
35630-2729
US

V. Phone/Fax

Practice location:
  • Phone: 256-766-8800
  • Fax: 256-766-8936
Mailing address:
  • Phone: 256-766-8800
  • Fax: 256-766-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IAN KYLE FAWCETT
Title or Position: OWNER
Credential: DMD
Phone: 256-766-8800