Provider Demographics
NPI:1154469062
Name:DICKERSON, MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 COBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5747
Mailing Address - Country:US
Mailing Address - Phone:937-847-8597
Mailing Address - Fax:
Practice Address - Street 1:26 W CENTER ST
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:OH
Practice Address - Zip Code:45327-1342
Practice Address - Country:US
Practice Address - Phone:937-855-7231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0222111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice