Provider Demographics
NPI:1407867385
Name:DICKEMORE, CHAD (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:DICKEMORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 WESTWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2305
Mailing Address - Country:US
Mailing Address - Phone:406-363-4214
Mailing Address - Fax:406-294-0967
Practice Address - Street 1:1201 WESTWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2305
Practice Address - Country:US
Practice Address - Phone:406-363-4214
Practice Address - Fax:406-294-0967
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT169213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT169OtherMT LICENSE
MT5787500001Medicare NSC