Healthcare Provider Details

I. General information

NPI: 1265674089
Provider Name (Legal Business Name): THOMAS TODD HICKMAN D.D.S.,P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S MAPLE AVE
CHESTERTOWN MD
21620-1626
US

IV. Provider business mailing address

202 S MAPLE AVE
CHESTERTOWN MD
21620-1626
US

V. Phone/Fax

Practice location:
  • Phone: 410-778-1297
  • Fax: 410-778-3552
Mailing address:
  • Phone: 410-778-1297
  • Fax: 410-778-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number11044
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11044
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: