Provider Demographics
NPI:1083697759
Name:DICKENSON, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:DICKENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WILLETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2485 NOTRE DAME BLVD
Mailing Address - Street 2:STE 350
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-7163
Mailing Address - Country:US
Mailing Address - Phone:530-343-5455
Mailing Address - Fax:530-924-4148
Practice Address - Street 1:2485 NOTRE DAME BLVD
Practice Address - Street 2:350
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-7161
Practice Address - Country:US
Practice Address - Phone:530-343-5455
Practice Address - Fax:530-343-9357
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-27
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice