Provider Demographics
NPI:1356301659
Name:DICKERSON LEE, MARY (DMD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:DICKERSON LEE
Suffix:
Gender:F
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:PO BOX 2048
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36652-2048
Mailing Address - Country:US
Mailing Address - Phone:251-432-4117
Mailing Address - Fax:251-964-4011
Practice Address - Street 1:1303 DR MARTIN L KING JR AVE
Practice Address - Street 2:FRANKLIN PRIMARY HEALTH CENTER INC
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36603-5341
Practice Address - Country:US
Practice Address - Phone:251-432-4117
Practice Address - Fax:251-964-4011
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLNO4503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51092208OtherBCBS
AL51092208OtherBCBS