Provider Demographics
NPI:1255472759
Name:DICKINSON, GREGORY THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
Last Name:DICKINSON
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 1:1851 ARLINGTON ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-3523
Mailing Address - Country:US
Mailing Address - Phone:941-365-7595
Mailing Address - Fax:941-953-5071
Practice Address - Street 1:1851 ARLINGTON ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3523
Practice Address - Country:US
Practice Address - Phone:941-365-7595
Practice Address - Fax:941-953-5071
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN7361122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT54900Medicare UPIN