Provider Demographics
NPI:1154460046
Name:DERRICKSON, WILLIAM L (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:L
Last Name:DERRICKSON
Suffix:
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 1:418 BRIDLEMERE AVE
Mailing Address - Street 2:
Mailing Address - City:INTERLAKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4309
Mailing Address - Country:US
Mailing Address - Phone:732-660-0071
Mailing Address - Fax:
Practice Address - Street 1:15 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3515
Practice Address - Country:US
Practice Address - Phone:732-840-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1021255001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice