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General NPI Number Information
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NPI Number | 1710373451
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Entity Type | Organization
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Legal Business Name | COLLEEN C HICKLE, DDS, INC.
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Dates
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Enumeration Date | 04/09/2015
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Last Update Date | 07/13/2017
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Provider Practice Location Address
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Address Line | 3690 ORANGE PL STE 550
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City | BEACHWOOD
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State | OH
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Zip | 44122-4475
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Country | US
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Telephone | 216-464-0500
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Fax | 216-464-0573
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Provider Business Mailing Address
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Address Line | 3690 ORANGE PL STE 550
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City | BEACHWOOD
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State | OH
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Zip | 44122-4475
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Country | US
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Telephone | 216-464-0500
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Fax | 216-464-0573
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Authorized Official
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Title or Position | OWNER
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Name | COLLEEN C GACKOWSKI
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Credential | DDS
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Telephone | 216-464-0500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 21356
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License Number State | OH
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