Provider Demographics
NPI:1184830614
Name:DICKEY, DOUGLAS
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:DICKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30169-0986
Mailing Address - Country:US
Mailing Address - Phone:770-479-3202
Mailing Address - Fax:
Practice Address - Street 1:8701 KNOX BRIDGE HWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:770-479-3202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA102121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice