Healthcare Provider Details

I. General information

NPI: 1841574258
Provider Name (Legal Business Name): ZACHARY HICKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E BROAD ST
COLUMBUS OH
43205-1381
US

IV. Provider business mailing address

9485 MENTOR AVE 112
MENTOR OH
44060-8724
US

V. Phone/Fax

Practice location:
  • Phone: 614-258-3880
  • Fax: 614-252-5873
Mailing address:
  • Phone: 440-255-8133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30023508
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: