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Hickory Hills Dental Care, LLC

Details

Name: Hickory Hills Dental Care, LLC
Jurisdiction: Alabama
Legal type: Domestic Limited Liability Company
Status: Exists
Date of registration: 14 Sep 2018 (6 years ago)
Entity Number: 000-529-693
Register Number: 000529693
County: Baldwin
Place of Formation: Lauderdale County
Registered Office Street Address: 1947 FLORENCE BLVDFLORENCE, AL 36530
Registered Office Street Address ZIP Code: 36530

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1205301777 2018-10-10 2018-10-10 1947 FLORENCE BLVD, FLORENCE, AL, 356302729, US 1947 FLORENCE BLVD, FLORENCE, AL, 356302729, US

Contacts
Phone +1 256-766-8800
Fax 2567668936

Authorized person
Name IAN KYLE FAWCETT
Role OWNER
Phone 2567668800

Taxonomy
Taxonomy Code 261QD0000X - Dental Clinic/Center
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 207491
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
HICKORY HILLS DENTAL CARE 401(K) PROFIT SHARING PLAN 2018 680503830 2019-04-29 HICKORY HILLS DENTAL CARE 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Signature of
Role Plan administrator
Date 2019-04-29
Name of individual signing BRUCE EVANS
Role Employer/plan sponsor
Date 2019-04-29
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401(K) PROFIT SHARING PLAN 2017 680503830 2018-06-11 HICKORY HILLS DENTAL CARE 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Signature of
Role Plan administrator
Date 2018-06-11
Name of individual signing BRUCE EVANS
Role Employer/plan sponsor
Date 2018-06-11
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401(K) PROFIT SHARING PLAN 2016 680503830 2017-10-03 HICKORY HILLS DENTAL CARE 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Signature of
Role Plan administrator
Date 2017-10-03
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401(K) PROFIT SHARING PLAN 2015 680503830 2016-09-26 HICKORY HILLS DENTAL CARE 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Signature of
Role Plan administrator
Date 2016-09-26
Name of individual signing BRUCE EVANS
Role Employer/plan sponsor
Date 2016-09-26
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401(K) PROFIT SHARING PLAN 2014 680503830 2015-10-12 HICKORY HILLS DENTAL CARE 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Signature of
Role Plan administrator
Date 2015-10-12
Name of individual signing BRUCE EVANS
Role Employer/plan sponsor
Date 2015-10-12
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401(K) PROFIT SHARING PLAN 2013 680503830 2014-10-15 HICKORY HILLS DENTAL CARE 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Signature of
Role Plan administrator
Date 2014-10-15
Name of individual signing BRUCE EVANS
Role Employer/plan sponsor
Date 2014-10-15
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401K SHARING PLAN 2012 680503830 2013-10-09 HICKORY HILLS DENTAL CARE 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Signature of
Role Plan administrator
Date 2013-10-08
Name of individual signing BRUCE EVANS
Role Employer/plan sponsor
Date 2013-10-08
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401K SHARING PLAN 2011 680503830 2012-05-21 HICKORY HILLS DENTAL CARE 11
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Plan administrator’s name and address
Administrator’s EIN 680503830
Plan administrator’s name HICKORY HILLS DENTAL CARE
Plan administrator’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630
Administrator’s telephone number 2567668800

Signature of
Role Plan administrator
Date 2012-05-21
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401K SHARING PLAN 2010 680503830 2011-09-29 HICKORY HILLS DENTAL CARE 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630

Plan administrator’s name and address
Administrator’s EIN 680503830
Plan administrator’s name HICKORY HILLS DENTAL CARE
Plan administrator’s address 1947 FLORENCE BLVD, FLORENCE, AL, 35630
Administrator’s telephone number 2567668800

Signature of
Role Plan administrator
Date 2011-09-29
Name of individual signing BRUCE EVANS
HICKORY HILLS DENTAL CARE 401-K 2009 630765319 2010-03-18 HICKORY HILLS DENTAL CARE No data
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-01-01
Business code 621210
Sponsor’s telephone number 2567668800
Plan sponsor’s DBA name HICKORY HILLS DENTAL CARE
Plan sponsor’s mailing address 1947 FLORENCE BOULEVARD, FLORENCE, AL, 35630
Plan sponsor’s address 1947 FLORENCE BOULEVARD, FLORENCE, AL, 35630

Plan administrator’s name and address
Administrator’s EIN 630765319
Plan administrator’s name HICKORY HILLS DENTAL CARE
Plan administrator’s address 1947 FLORENCE BOULEVARD, FLORENCE, AL, 35630
Administrator’s telephone number 2567668800

Signature of
Role Plan administrator
Date 2010-03-18
Name of individual signing BRUCE EVANS
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
FAWCETT, IAN Agent 2138 HELTON DRFLORENCE, AL 35630

Related by officers

FAWCETT, IAN

Florence Family Dental, LLC Fawcett Family Real Estate, LLC

Related by address

No related companies by address

Date of last update: 14 Aug 2024

Sources: Alabama Secretary of State

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