Healthcare Provider Details

I. General information

NPI: 1891799615
Provider Name (Legal Business Name): ANDREW M. SICKLICK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 GROVE AVE STE 110
CEDARHURST NY
11516-2302
US

IV. Provider business mailing address

123 GROVE AVE STE 110
CEDARHURST NY
11516-2302
US

V. Phone/Fax

Practice location:
  • Phone: 516-569-5559
  • Fax: 516-569-3574
Mailing address:
  • Phone: 516-569-5559
  • Fax: 516-569-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number049916
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: