Healthcare Provider Details

I. General information

NPI: 1912200031
Provider Name (Legal Business Name): JOHN E HICKORY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2010
Last Update Date: 12/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 ANN ST
WILMINGTON NC
28401-4662
US

IV. Provider business mailing address

412 ANN ST
WILMINGTON NC
28401-4662
US

V. Phone/Fax

Practice location:
  • Phone: 910-763-8163
  • Fax: 910-763-4505
Mailing address:
  • Phone: 910-763-8163
  • Fax: 910-763-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number06633
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: