MEDICARE: MRS. ANDREA HICKSON-MOORE RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	024517	NY
2	124Q00000X	Dental Hygienist	001958	NY

General Provider Information

NPI Number	:	1730506924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANDREA HICKSON-MOORE RDH

Provider Business Mailing Address
First Line	:	361 MAPLE ST
Second Line	:	9B
City	:	BROOKLYN
State	:	NY
Zip	:	11225-5134
Country	:	US
Telephone Number	:	347-787-2259
Fax Number	:

Provider Business Practice Location Address
First Line	:	361 MAPLE ST
Second Line	:	9B
City	:	BROOKLYN
State	:	NY
Zip	:	11225-5134
Country	:	US
Telephone Number	:	347-787-2259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2014
Last Update Date	:	03/25/2014

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