Provider Demographics
NPI:1548321177
Name:HICKMAN, CHARLES JESSE III (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JESSE
Last Name:HICKMAN
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 MIDWESTERN PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2342
Mailing Address - Country:US
Mailing Address - Phone:940-696-1544
Mailing Address - Fax:940-696-0203
Practice Address - Street 1:2304 MIDWESTERN PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2342
Practice Address - Country:US
Practice Address - Phone:940-696-1544
Practice Address - Fax:940-696-0203
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD10707OtherBCBS PROVIDER #
00830RMedicare ID - Type Unspecified
TXT13829Medicare UPIN