Healthcare Provider Details

I. General information

NPI: 1275131948
Provider Name (Legal Business Name): HICKORY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9556 S ROBERTS RD
HICKORY HILLS IL
60457-2239
US

IV. Provider business mailing address

3924 S ARCHER AVE UNIT D
CHICAGO IL
60632-1116
US

V. Phone/Fax

Practice location:
  • Phone: 708-608-0095
  • Fax:
Mailing address:
  • Phone: 773-819-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PRASANTH DOMMARAJU
Title or Position: OWNER
Credential:
Phone: 630-247-7216